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Rosen's Emergency Medicine:

Concepts and Clinical Practice 9th


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ROSEN’S
EMERGENCY MEDICINE
Concepts and Clinical Practice
9th Edition

Rosen’s
Emergency Medicine
Concepts and Clinical Practice

Editor-in-Chief
Ron M. Walls, MD
Executive Vice President and Chief Operating Officer, Brigham
Health; Neskey Family Professor of Emergency Medicine, Harvard
Medical School, Boston, Massachusetts

Senior Editors
Robert S. Hockberger, MD Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS
Emeritus Professor of Emergency Medicine, David Geffen School Medical Director, Los Angeles County EMS Agency; Professor
of Medicine at UCLA; Chair Emeritus, Department of Emergency of Clinical Medicine and Pediatrics, David Geffen School of
Medicine, Harbor-UCLA Medical Center, Los Angeles, California Medicine at UCLA; EMS Fellowship Director, Department of
Emergency Medicine, Harbor-UCLA Medical Center, Torrance,
California

Editors
Katherine Bakes, MD Amy H. Kaji, MD, PhD
Associate Professor, Department of Emergency Medicine, Associate Professor, Emergency Medicine, David Geffen School of
University of Colorado School of Medicine; Clinical Director Medicine at UCLA; Vice Chair of Academic Affairs, Department
of Community Affairs, Director, At-Risk Intervention and of Emergency Medicine, Harbor-UCLA, Los Angeles, California
Mentoring (AIM), Denver Health; Denver, Colorado
Michael VanRooyen, MD, MPH
Jill Marjorie Baren, MD, MBE, FACEP, FAAP Chairman, Emergency Medicine, Brigham and Women’s Hospital
Professor and Chair, Emergency Medicine, Perelman School of Professor, Department of Emergency Medicine, Harvard Medical
Medicine; Chief, Emergency Services, University of Pennsylvania School; Boston, Massachusetts; Director, Harvard Humanitarian
Health System, Philadelphia, Pennsylvania Initiative, Harvard University, Cambrige, Massachusetts

Timothy B. Erickson, MD, FACEP, FACMT, FAACT Richard D. Zane, MD, FAAEM
Chief, Division of Medical Toxicology, Department of Emergency The George B. Boedecker Professor and Chair, Department of
Medicine, Brigham and Women’s Hospital; Harvard Medical Emergency Medicine, University of Colorado School of Medicine;
School, Boston, Massachusetts; Faculty, Harvard Humanitarian Executive Director, Emergency Services, University of Colorado
Initiative, Cambridge, Massachusetts Health, Aurora, Colorado

Andy S. Jagoda, MD
Professor and Chair, Department of Emergency Medicine, Icahn
School of Medicine at Mount Sinai; Professor and Chair,
Emergency Medicine, Mount Sinai School of Medicine, New York,
New York

VOLUME 1
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

ROSEN’S EMERGENCY MEDICINE: CONCEPTS AND CLINICAL PRACTICE, ISBN: 978-0-323-35479-0


NINTH EDITION  Part Vol 1: 9996111695
Part Vol 2: 9996111636

Copyright © 2018 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1992, 1988, and 1983.

Library of Congress Cataloging-in-Publication Data

Names: Walls, Ron M., editor. | Hockberger, Robert S., editor. | Gausche-Hill, Marianne,
editor.
Title: Rosen’s emergency medicine : concepts and clinical practice / [edited by] Ron M.
Walls, Robert S. Hockberger, Marianne Gausche-Hill.
Other titles: Emergency medicine
Description: Ninth edition. | Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2016055133 | ISBN 9780323354790 (hardcover : alk. paper) | ISBN
9789996111693 (v. 1: hardcover : alk. paper) | ISBN 9996111695 (v. 1: hardcover : alk.
paper) | ISBN 9789996111631 (v. 2 : hardcover : alk. paper) | ISBN 9996111636 (v. 2:
hardcover : alk. paper)
Subjects: | MESH: Emergencies | Emergency Medicine
Classification: LCC RC86.7 | NLM WB 105 | DDC 616.02/5—dc23
LC record available at https://lccn.loc.gov/2016055133

Executive Content Strategist: Kate Dimock


Senior Content Development Specialist: Deidre Simpson
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Renee Duenow

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1


Acknowledgments
To my wife Barb, thank you for the endless love, support, and I am forever grateful to my husband Kenneth and my two sons,
patience and for being my closest and most trusted advisor. To my Noah and Andrew, for their everlasting love and for their tolerance
children, Andrew, Blake, and Alexa, thank you for making my life of my long hours and work passions. I love you all so much. Mom
so complete that I can savor fully the joy and privilege of helping and Dad—thanks for such a great start in life and for continuing
others. To David and Sharon Neskey, thank you for your vision to tell me how proud you are. It makes a difference, no matter
and generosity in support of me and of our specialty. To my how old you get. I have deep appreciation for my authors and
colleagues at Brigham and Women’s Hospital and the Department fellow editors who have enriched my knowledge of emergency
of Emergency Medicine at Harvard Medical School, thank you for medicine and strengthened my clinical practice through your
the constant inspiration to drive toward excellence. To Peter Rosen outstanding contributions to this book.
and John Marx, thank you for showing the way with such extraor- JMB
dinary determination and clarity. And to Bob, Marianne, and our
superb editors, you are the best team that one could hope for. I extend my thanks to Valerie, Camille, Isabelle, Celeste, Julian,
Thank you for bringing so much brilliance, energy, and commit- and my parents. I also give appreciation to my mentors and col-
ment to make this edition so special. leagues in Emergency Medicine, Toxicology, Wilderness Medicine,
RMW and Global and Humanitarian Health, with special thanks to
Paracelsus and Alice Hamilton.
To Peter for his inspiration and mentorship over the years; to John TBE
for sharing his friendship and commitment to excellence; to Ron
for his leadership and renewed vision for the “bible” of Emergency To all the faculty, residents, and staff at the Mount Sinai Depart-
Medicine; to Marianne for her creativity and endless enthusiasm; ment of Emergency Medicine—their commitment to excellence
to Amy, Andy, Jill, Katie, Mike, Tim, and Rich for their willingness in clinical care, teaching, and research inspires me every day. To
to add this burden of love to their already busy lives; to Kate and Silvana, my wife and closest colleague, for her support and for
Dee for their vigilance and professionalism; and to Patty, for keeping me focused on the important things in life. To Ron, for
bringing color and meaning to my life. being a mentor throughout my career; and to John, whose memory
RSH lives forever.
ASJ
I would like to thank my family for their continued understanding
of my work to improve emergency care. My husband David and As a first-time section editor, I am grateful to Ron, Bob, and
our three children Katie, Jeremiah, and Sarah provide the love, joy, Marianne for their incredible mentorship and patience with me,
and encouragement that makes participation on endeavors as and to Dee and Kate for their editorial guidance. This has been a
important as this text worthwhile. Finally, I would like to thank tremendous learning experience and opportunity. Thank you!
Drs. Ron Walls, Robert Hockberger, and all the associate editors AHK
for their incredible leadership in the creation of a truly state of
the art textbook. With love and thanks to my family, ever patient and ever sup-
MGH portive. And especially to my daughter, Isabella VanRooyen, who
is striving toward a career in medicine. May she be as fortunate
I would like to thank my wonderful family, Peter, Sam, Jessie, and as I was to find wonderful colleagues, inspiring mentors, and
Avery, who sacrificed their time with me for the publication generous patients to lead her into a fulfilling career in a field that
of this text. I would also like to thank my mentors, including she loves.
Marianne Gausche-Hill and Bob Hockberger, for their constant MV
support and positive encouragement. And finally, I would like to
thank Ron Walls, my dear friend and ultimate mentor, who has It is both humbling and a privilege to be associated with this text
looked out for me and inspired me since medical school. In many and those who started it all— Rosen, Marx, Walls, and Hockber-
ways, my success belongs more to him that it does to me. I am ger—the founders of our discipline.
eternally grateful for all of you. RDZ
KB

v
Contributors
Gallane Abraham, MD Aaron N. Barksdale, MD
Assistant Professor, Emergency Medicine, Icahn School of Assistant Professor, Emergency Medicine, University of
Medicine at Mount Sinai, New York, New York Nebraska Medical Center, Omaha, Nebraska

Michael K. Abraham, MD, MS Christopher W. Baugh, MD, MBA


Clinical Assistant Professor, Emergency Medicine, University of Director of Observation Medicine, Emergency Medicine,
Maryland School of Medicine, Baltimore, Maryland; Brigham and Women’s Hospital, Boston, Massachusetts
Attending Physician, Emergency Medicine, Upper
Chesapeake Health System, Bel Air, Maryland Bruce M. Becker, MD, MPH, FACEP
Professor, Emergency Medicine and Behavioral and Social
Saadia Akhtar, MD Science, Warren Alpert School of Medicine, Brown
Associate Dean for Graduate Medical Education and Residency University, Providence, Rhode Island
Program Director, Department of Emergency Medicine,
Mount Sinai Beth Israel, New York, New York Rachel R. Bengtzen, MD
Assistant Professor, Emergency Medicine and Family Medicine
Steven E. Aks, DO (Sports Medicine), Oregon Health and Science University,
Director, The Toxikon Consortium, Department of Emergency Portland, Oregon
Medicine, Cook County Health and Hospitals System;
Professor of Emergency Medicine, Department of Emergency Rachel Berkowitz, MD
Medicine, Rush University, Chicago, Illinois Attending Physician, Department of Emergency Medicine,
Kaiser Permanente South San Francisco Medical Center, San
James T. Amsterdam, DMD, MD, MMM, FACEP, FACPE Francisco, California
Senior Vice-President/Chief Medical Officer, Administration,
Saint Vincent Hospital Allegheny Health Network, Erie, Kristin Berona, MD
Pennsylvania; Professor of Clinical Emergency Medicine, Assistant Professor of Emergency Medicine, LAC USC Medical
Department of Emergency Medicine, Penn State University Center, Keck School of Medicine, Los Angeles, California
College of Medicine, Hershey, Pennsylvania; Adjunct
Professor of Emergency Medicine, Department of Emergency Marian E. Betz, MD, MPH
Medicine, Drexel University College of Medicine,
Associate Professor, Department of Emergency Medicine,
Philadelphia, Pennsylvania
University of Colorado School of Medicine, Aurora,
Colorado
Felix K. Ankel, MD
Vice President, Health Professional Education, HealthPartners, Michelle H. Biros, MD, MS
Bloomington, Minnesota; Professor, Emergency Medicine,
Professor, Emergency Medicine, University of Minnesota
University Of Minnesota, Minneapolis, Minnesota
Medical School; Attending Physician, Emergency Medicine,
Hennepin County Medical Center, Minneapolis, Minnesota
Robert T. Arntfield, MD, FRCPC, FCCP, RDMS
Assistant Professor, Division of Emergency Medicine and Robert A. Bitterman, MD, JD
Critical Care Medicine, Western University; Attending
President, Bitterman Health Law Consulting Group, Sarasota,
Physician, Emergency Medicine, Critical Care Medicine and
Florida
Trauma, London Health Sciences Centre, London, Ontario,
Canada
Thomas H. Blackwell, MD
Tom P. Aufderheide, MD Assistant Dean, Longitudinal Clinical Education, University of
South Carolina School of Medicine Greenville; Professor,
Professor of Emergency Medicine, Department of Emergency
Department of Emergency Medicine, Greenville Health
Medicine, Medical College of Wisconsin, Milwaukee,
System, Greenville, South Carolina
Wisconsin
Frederick C. Blum, BA, MD
Katherine Bakes, MD
Associate Professor, Departments of Pediatrics and Emergency
Associate Professor, Department of Emergency Medicine,
Medicine, West Virginia University School of Medicine,
University of Colorado School of Medicine; Clinical Director
Morgantown, West Virginia
of Community Affairs, Director, At-Risk Intervention and
Mentoring (AIM), Denver Health; Denver, Colorado

vii
viii Contributors

Ira J. Blumen, MD, FACEP E. Bradshaw Bunney, MD, FACEP


Professor, Department of Medicine, Section of Emergency Associate Professor, Residency Director, Emergency Medicine,
Medicine, University of Chicago; Medical and Program University of Illinois at Chicago, Chicago, Illinois
Director, University of Chicago Aeromedical Network
(UCanada), University of Chicago Medicine, Chicago, Illinois Michael J. Burns, MD
Clinical Professor, Departments of Emergency Medicine and
Edward B. Bolgiano, MD Medicine, Division of Infectious Diseases, University of
Assistant Professor, Department of Emergency Medicine, California Irvine School of Medicine, Irvine, California;
University of Maryland School of Medicine, Baltimore, Attending Physician, Department of Emergency Medicine,
Maryland University of California Irvine Medical Center, Orange,
California
Michael C. Bond, MD
Associate Professor, Emergency Medicine, University of John H. Burton, MD
Maryland School of Medicine, Baltimore, Maryland Chair, Professor of Emergency Medicine, Department of
Emergency Medicine, Carilion Clinic, Roanoke, Virginia
Kelly Bookman, MD
Associate Professor, Emergency Medicine, University of Katharine Carroll Button, BA, BS, MS, MD
Colorado, Denver, Colorado Clinical Fellow, Pediatric Emergency Medicine, Boston
Children’s Hospital, Boston, Massachusetts
Joelle Borhart, MD
Assistant Professor, Emergency Medicine, Georgetown Richard L. Byyny, MD, MSc
University, Washington, DC Associate Professor, Emergency Medicine, Denver Health
Medical Center, Denver, Colorado; Assistant Professor,
William J. Brady, MD Emergency Medicine, University of Colorado, Aurora,
Professor of Emergency Medicine, Department of Emergency Colorado
Medicine; Professor of Medicine, Department of Medicine,
University of Virginia, Charlottesville, Virginia John D. Cahill, MD
Senior Attending in Emergency Medicine and Infectious
Sabina A. Braithwaite, MPH Disease, Global Health Fellowship Director, Emergency
Associate Professor, Division of Emergency Medicine; Program Medicine, St. Luke’s Roosevelt Hospital Center, New York,
Director, EMS Fellowship, Washington University in St. Louis New York; Senior Lecturer, International Health and Tropical
School of Medicine, St. Louis, Missouri Medicine, The Royal College of Surgeons, Dublin, Ireland

Leah Bright, DO Andrea Carlson, MD


Assistant Professor, Emergency Medicine Department, Johns Assistant Residency Director, Director of Toxicology, Emergency
Hopkins Medical Institute, Baltimore, Maryland Medicine, Advocate Christ Hospital, Oak Lawn, Illinois

Aaron Brody, MD Jeffrey M. Caterino, MD, MPH


Assistant Professor, Emergency Medicine, Wayne State Associate Professor, Departments of Emergency and Internal
University, Detroit, Michigan Medicine, The Ohio State University, Columbus, Ohio

Calvin A. Brown III, MD Andrew K. Chang, MD, MS


Assistant Professor of Emergency Medicine, Director of Faculty Vincent P. Verdile, MD Endowed Chair in Emergency Medicine,
Affairs, Harvard Medical School; Attending Physician, Professor of Emergency Medicine, Vice Chair of Research
Department of Emergency Medicine, Brigham and Women’s and Academic Affairs, Department of Emergency Medicine,
Hospital, Boston, Massachusetts Albany Medical College, Albany, New York

James E. Brown, MD, MMM Jennifer C. Chen, MD, MPH


Chair, Department of Emergency Medicine, Wright State Emergency Medicine, Harbor-UCLA Medical Center, Torrance,
University Boonshoft School of Medicine, Dayton, Ohio California; Clinical Assistant Professor of Medicine, School
of Medicine, David Geffen School of Medicine at UCLA, Los
Jennie Alison Buchanan, MD Angeles, California
Attending Physician, Emergency Medicine, Denver Health and
Hospital Authority; Staff Physician, Medical Toxicology, Rachel L. Chin, MD
Rocky Mountain Poison and Drug Center, Denver, Colorado; Professor of Emergency Medicine, Department of Emergency
Associate Professor, Emergency Medicine, University of Medicine, UCSF School of Medicine, San Francisco General
Colorado School of Medicine, Aurora, Colorado Hospital, San Francisco, California

Jeffrey Bullard-Berent, MD Esther K. Choo, MD, MPH


Professor, Departments of Emergency Medicine and Pediatrics, Assistant Professor, Emergency Medicine, Warren Alpert Medical
University of New Mexico, Albuquerque, New Mexico School, School of Public Health, Brown University,
Providence, Rhode Island
Contributors ix

Richard F. Clark, MD Daniel F. Danzl, MD


Professor, Emergency Medicine, UCSD School of Medicine; Professor and Chair, Department of Emergency Medicine,
Director, Division of Medical Toxicology, UCSD Medical ICAR, Zürich, Switzerland; Clinical Professor, Department of
Center; Medical Director, San Diego Division, California Emergency Medicine, Stanford University Medical Center,
Poison Control System, San Diego, California Stanford, California

Ilene Claudius, MD Mohamud R. Daya, MD, MS


Associate Professor, Emergency Medicine, University of South Professor of Emergency Medicine Department of Emergency
Carolina Keck School of Medicine, Los Angeles, California Medicine, Oregon Health and Science University, Portland,
Oregon
Wendy C. Coates, MD
Professor of Clinical Medicine, David Geffen School of Robert A. De Lorenzo, MD, MSM, MSCI
Medicine, University of California, Los Angeles, Los Angeles, Professor, Department of Emergency Medicine, University of
California; Senior Faculty/Education Specialist, Emergency Texas Health Scinece Center at San Antonio, San Antonio,
Medicine, Harbor-UCLA Medical Center, Torrance, Texas; Professor, Departement of Military and Emergency
California Medicine, Uniformed Services University of the Health
Sciences, Bethesda, Maryland
Jon B. Cole, MD
Medical Director, Minnesota Poison Control System; Faculty, Ken Deitch, DO
Emergency Physician, Department of Emergency Medicine, Research Director, Department of Emergency Medicine, Albert
Hennepin County Medical Center; Associate Professor of Einstein Medical Center, Philadelphia, Pennsylvania
Emergency Medicine, Department of Emergency Medicine,
University of Minnesota, Minneapolis, Minnesota Robert W. Derlet, MD
Professor, Emergency Department, University of California,
Michael Alan Cole, MD Davis, School of Medicine, Sacramento, California
Assistant Professor, Emergency Medicine, University of
Michigan Medical School, Ann Arbor, Michigan Shoma Desai, MD
Assistant Professor, Department of Emergency Medicine, LAC +
Christopher B. Colwell, MD USC Medical Center, Los Angeles, California
Chief of Emergency Medicine, Zuckerberg San Francisco
General Hospital and Trauma Center; Professor and Vice- Valerie A. Dobiesz, MD, MPH, FACEP
Chair, Department of Emergency Medicine, UCSF School of Director of External Programs: STRATUS Center for Medical
Medicine, San Francisco, California Simulation, Brigham and Women’s Hospital; Harvard
Humanitarian Initiative, Harvard Medical School, Boston,
Robert Cooper, MD Massachusetts
Assistant Professor of Emergency Medicine, Medical Director
Ohio State University Health Plan, The Ohio State University, Alan A. Dupré, MD
Columbus, Ohio Assistant Professor, Department of Emergency Medicine,
Boonshoft School of Medicine, Wright State University,
Zara Cooper, MD, MSc Dayton, Ohio
Associate Surgeon, Division of Trauma, Burns and Surgical
Critical Care, Department of Surgery, Brigham and Women’s Joshua Samuel Easter, MD, MSc
Hospital; Assistant Professor of Surgery, Harvard Medical Assistant Professor, Emergency Medicine, University of Virginia,
School, Boston, Massachusetts Charlottesville, Virginia; Physician, Emergency Medicine,
Bon Secours St. Mary’s Hospital, Richmond, Virginia
Randolph J. Cordle, MD
Medical Director, Division of Pediatric Emergency Medicine, Wesley P. Eilbert, MD
Emergency Medicine, Carolinas Medical Center, Levine Associate Professor of Clinical Emergency Medicine,
Children’s Hospital, Charlotte, North Carolina Department of Emergency Medicine, University of Illinois,
College of Medicine, Chicago, Illinois
Brian Niall Corwell, MD
Assistant Professor, Department of Emergency Medicine and Matthew Emery, MD, FACEP
Department of Orthopaedics, University of Maryland School Assistant Professor, Associate Director for Academic Affairs,
of Medicine, Baltimore, Maryland Department of Emergency Medicine, Lead Clerkship
Director, Fourth-Year Elective in Emergency Medicine,
Todd J. Crocco, MD, FACEP Department of Emergency Medicine, Michigan State
Chief Business Development Officer, WVU Health Sciences University College of Human Medicine; Educational
Center; Professor, Department of Emergency Medicine, West Assistant for Simulation, Emergency Medicine, Grand Rapids
Virginia University, Morgantown, West Virginia Medical Education Partners, Grand Rapids, Michigan

Shawn M. D’Andrea, MD, MPH


Instructor of Emergency Medicine, Emergency Medicine,
Harvard Medical School; Attending Physician, Emergency
Medicine, Brigham and Women’s Hospital, Boston,
Massachusetts
x Contributors

Timothy B. Erickson, MD, FACEP, FACMT, FAACT Jeffrey M. Goodloe, MD, NRP, FACEP
Chief, Division of Medical Toxicology, Department of Professor and EMS Section Chief, Director, Oklahoma Center
Emergency Medicine, Brigham and Women’s Hospital; for Prehospital and Disaster Medicine Department of
Harvard Medical School, Boston, Massachusetts; Faculty, Emergency Medicine, University of Oklahoma School of
Harvard Humanitarian Initiative, Cambridge, Massachusetts Community Medicine—Tulsa; Oklahoma Medical Director,
Medical Control Board EMS System for Metropolitan
Madonna Fernández-Frackelton, MD Oklahoma City and Tulsa, Tulsa, Oklahoma
Program Director, Emergency Medicine, Harbor-UCLA Medical
Center, Torrance, California; Professor of Medicine, David Eric Goralnick, MD, MS
Geffen School of Medicine, UCLA, Los Angeles, California Medical Director, Emergency Preparedness, Brigham and
Women’s Healthcare; Assistant Professor, Emergency
John T. Finnell, MD, MSc Medicine, Harvard Medical School; Instructor, Department
Associate Professor of Clinical Emergency Medicine, Indiana of Health Policy and Management, Harvard TH Chan School
University, Indianapolis, Indiana of Public Health, Boston, Massachusetts

Charles J. Fox, MD, FACS Diane L. Gorgas, MD


Chief, Vascular Surgery, Department of Surgery, Denver Health Professor, Department of Emergency Medicine, The Ohio State
Medical Center; Associate Professor of Surgery, Department University; Executive Director, Office of Global Health, The
of Surgery, University of Colorado School of Medicine, Ohio State University, Columbus, Ohio
Denver, Colorado
Louis Graff IV, MD, FACEP, FACP
Benjamin W. Friedman, MD, MS Professor of Traumatology and Emergency Medicine,
Associate Professor, Emergency Medicine, Albert Einstein Emergency Medicine, University of Connecticut School of
College of Medicine; Attending Physician, Emergency Medicine, Farmington, Connecticut; Medical Director of
Medicine, Montefiore Medical Center, Bronx, New York Quality, Performance Improvement, Associate Director of
Emergency Medicine, Emergency Medicine, Hospital of
Joel M. Geiderman, MD, FACEP Central Connecticut, New Britain, Connecticut
Professor of Medicine, Department of Medicine, Division of
Emergency Medicine, David Geffen School of Medicine at Thomas J. Green, MSc, MD
UCLA; Co-Chairman and Professor of Emergency Medicine, Clinical Assistant Professor, Department of Emergency
Department of Emergency Medicine, Cedars-Sinai Medical Medicine, University of British Columbia, Vancouver, British
Center, Los Angeles, California; Medical Director, Beverly Columbia, Canada
Hills Fire Department, California
Eric A. Gross, MD
Nicholas Genes, MD, PhD Clinical Professor of Emergency Medicine, Quality Director,
Associate Professor, Department of Emergency Medicine, Icahn Department of Emergency Medicine, University of
School of Medicine at Mount Sinai, New York, New York California, Davis, Sacramento, California

Carl A. Germann, MD, FACEP Phillip F. Gruber, MD


Associate Professor, Emergency Medicine, Tufts University Assistant Professor of Clinical Emergency Medicine, LAC USC
School of Medicine, Boston, Massachusetts; Attending Department of Emergency Medicine, Keck School of
Physician, Emergency Department, Maine Medical Center, Medicine of USC, Los Angeles, California
Portland, Maine
Kama Guluma, MD
Jonathan M. Glauser, MD, MBA, FACEP Clinical Professor, Department of Emergency Medicine,
Professor, Emergency Medicine, Case Western Reserve University of California San Diego, San Diego, California
University; Faculty, Emergency Medicine Residency,
MetroHealth Medical Center, Cleveland, Ohio Leon Gussow, MD
Lecturer, Emergency Medicine, University of Illinois; Instructor,
Steven A. Godwin, MD, FACEP Emergency Medicine, Rush Medical College, Chicago, Illinois
Professor and Chair, Emergency Medicine, Assistant Dean,
Simulation Education, University of Florida COM- Joshua Guttman, MD, FRCPC, FAAEM
Jacksonville, Jacksonville, Florida Assistant Professor, Department of Emergency Medicine, Long
Island Jewish Medical Center, Hofstra-Northwell School of
Scott A. Goldberg, MD, MPH Medicine, New Hyde Park, New York
Director of Emergency Medical Services, Brigham and Women’s
Hospital; Instructor of Emergency Medicine, Harvard Elizabeth J. Haines, DO
Medical School, Boston, Massachusetts Assistant Professor, Emergency Medicine and Pediatrics, New
York University School of Medicine, New York, New York
Contributors xi

N. Stuart Harris, MD, MFA, FRCP Edinburgh Robert S. Hoffman, MD, FAACT, FACMT, FRCP Edinburgh
Chief, Division of Wilderness Medicine, Fellowship Director, Professor, Emergency Medicine and Medicine, New York
MGH Wilderness Medicine Fellowship, Department of University School of Medicine; Attending Physician,
Emergency Medicine, Massachusetts General Hospital; Department of Emergency Medicine, Bellevue Hospital
Associate Professor, Emergency Medicine, Harvard Medical Center, New York, New York
School, Boston, Massachusetts
Christopher Hogrefe, MD
Danielle Hart, MD Assistant Professor, Departments of Medicine, Emergency
Associate Program Director and Director of Simulation, Medicine, and Orthopaedic Surgery, Northwestern University
Department of Emergency Medicine, Hennepin County Feinberg School of Medicine, Chicago, Illinois
Medical Center, Minneapolis, Minnesota
Jeffrey A. Holmes, MD
Benjamin W. Hatten, MD, MPH Attending Physician, Emergency Department, Maine Medical
Assistant Professor, Emergency Medicine, University of Center, Portland, Maine
Colorado–School of Medicine, Aurora, Colorado; Medical
Toxicologist, Rocky Mountain Poison and Drug Center, Jason A. Hoppe, DO
Denver Health Medical Center, Denver, Colorado Associate Professor, Emergency Medicine, University of
Colorado School of Medicine, Aurora, Colorado
Jag S. Heer, MD
Associate Professor of Clinical Medicine, David Geffen School Timothy Horeczko, MD, MSCR
of Medicine at University of California at Los Angeles, Los Department of Emergency Medicine, Harbor-UCLA Medical
Angeles, California; Attending Faculty Physician, Department Center, Torrance, California
of Emergency Medicine, Kern Medical Center, Bakersfield,
California Christopher Hoyte, MD
Fellowship Director, Associate Medical Director, Rocky
Carlton E. Heine, MD, PhD Mountain Poison and Drug Center; Director, Medical
Clinical Associate Professor, Elson S. Floyd College of Medicine, Toxicology Clinic, Section of Medical Toxicology,
Washington State University, Spokane Academic Center, Department of Emergency Medicine, University of Colorado
Spokane, Washington School of Medicine, Denver, Colorado

Jason D. Heiner, MD Daniel Hryhorczuk, MD, MPH


Clinical Assistant Professor, Division of Emergency Medicine, Director, Environmental Health, Center for Global Health,
University of Washington, Seattle, Washington University of Illinois College of Medicine, Chicago, Illinois

Robert G. Hendrickson, MD Margaret G. Huang, MD


Professor, Department of Emergency Medicine, Oregon Health Clinical Instructor, Department of Pediatric Emergency
and Science University; Program Director, Fellowship in Medicine, Rady Children’s Hospital, UC San Diego Medical
Medical Toxicology, Oregon Health and Science University; Center, San Diego, California; Clinical Instructor,
Associate Medical Director, Medical Toxicologist, Oregon Department of Pediatric Emergency Medicine, Rady
Poison Center, Portland, Oregon Children’s Hospital, UC San Diego Medical Center, San
Diego, California
H. Gene Hern, Jr, MD, MS
Vice Chair, Education, Emergency Medicine, Alameda Health Robert David Huang, MD
System—Highland Hospital, Oakland, California; Association Clinical Ultrasound Fellowship Director, Associate Director of
Clinical Professor, University of California, San Francisco, Clinical Ultrasound, Assistant Residency Program Director,
California Clinical Instructor, University of Michigan Health System,
Ann Arbor, Michigan
Jamie M. Hess, MD
Director of Medical Student Education, Emergency Department, J. Stephen Huff, MD
University of Wisconsin School of Medicine and Public Professor of Emergency Medicine and Neurology, Department
Health, Madison, Wisconsin of Emergency Medicine, University of Virginia,
Charlottesville, Virginia
Christopher M. Hicks, MD, MEd, FRCPC
Staff Emergency Physician, Trauma Team Leader, Department of Christopher L. Hunter, MD, PhD
Emergency Medicine, St. Michael’s Hospital; Assistant Clinical Assistant Professor, Emergency Medicine, University of
Professor, Department of Medicine, University of Toronto, Central Florida College of Medicine; Attending Physician,
Toronto, Ontario, Canada Emergency Medicine, Orlando Regional Medical Center;
Associate EMS Medical Director, Health Services, Orange
Robert S. Hockberger, MD County, Orlando, Florida
Emeritus Professor of Emergency Medicine, David Geffen
School of Medicine at UCLA; Chair Emeritus, Department
of Emergency Medicine, Harbor-UCLA Medical Center,
Los Angeles, California
xii Contributors

Alson S. Inaba, MD, FAAP Julius (Jay) A. Kaplan, MD, FACEP


Associate Professor of Pediatrics, Department of Pediatrics, Immediate Past-President, American College of Emergency
University of Hawaii John A. Burns School of Medicine; Physicians; Vice Chair, Department of Emergency Medicine,
PEM Attending Physician, Emergency Department, Kpaiolani Ochsner Health System, New Orleans, Louisiana
Medical Center for Women and Children; Course Director,
Pediatric Advanced Life Support, The Queen’s Medical Dan Katz, MD, DTMH
Center, Honolulu, Hawaii; PEM Attending Physician, Attending Physician and Medical Director of Academic Affairs,
Emergency Medicine Physicians (EMP), Canton, Ohio Department of Emergency Medicine, Cedars-Sinai Medical
Center; Assistant Professor of Clinical Medicine, Department
Kenneth V. Iserson, MD, MBA of Medicine, Division of Emergency Medicine, David Geffen
Professor Emeritus, Emergency Medicine, The University of School of Medicine at UCLA, Los Angeles, California
Arizona, Tucson, Arizona
Stephanie Kayden, MD, MPH
Janetta L. Iwanicki, BA, MD Chief, Division of International Emergency Medicine and
Medical Toxicology, Attending Physician, Department of Humanitarian Programs, Department of Emergency
Medical Toxicology, Rocky Mountain Poison and Drug Medicine, Brigham and Women’s Hospital, Harvard Medical
Center; Emergency Medicine Attending Physician, School, Boston, Massachusetts
Department of Emergency Medicine, Denver Health, Denver,
Colorado; Assistant Professor, Department of Emergency Ryan D. Kearney, MD
Medicine, University of Colorado School of Medicine, Fellow, Emergency Medicine, Seattle Children’s Hospital, Seattle,
Aurora, Colorado Washington

Andy S. Jagoda, MD Matthew P. Kelly, MD


Professor and Chair, Department of Emergency Medicine, Icahn Assistant Professor, Department of Emergency Medicine,
School of Medicine at Mount Sinai; Professor and Chair, University of Pennsylvania, Philadelphia, Pennsylvania
Emergency Medicine, Mount Sinai School of Medicine,
New York, New York Hyung T. Kim, MD
Associate Professor of Clinical Emergency Medicine,
Timothy G. Janz, MD Department of Emergency Medicine, University of Southern
Professor, Department of Emergency Medicine, Wright State California, Los Angeles, Los Angeles, California
University—Boonshoft School of Medicine; Professor,
Pulmonary/Critical Care Division, Department of Internal Heidi Harbison Kimberly, MD, FACEP
Medicine, Wright State University—Boonshoft School of
Chief, Division of Emergency Ultrasound, Brigham and
Medicine, Dayton, Ohio
Women’s Hospital; Assistant Professor of Emergency
Medicine, Department of Emergency Medicine, Harvard
Alan E. Jones, MD Medical School, Boston, Massachusetts
Professor and Chair, Department of Emergency Medicine,
University of Mississippi School of Medicine, Jackson, Jeffrey A. Kline, MD
Mississippi
Professor and Vice Chair of Research, Department of Emergency
Medicine, Indiana University School of Medicine,
Emily Martin Jones, MD Indianapolis, Indiana
Assistant Professor, Departments of Medicine and Orthopaedic
Surgery, Northwestern University Feinberg School of Kristi L. Koenig, MD, FACEP, FIFEM, FAEMS
Medicine, Chicago, Illinois
Professor of Emergency Medicine and Public Health, Director,
Center for Disaster Medical Sciences, Founding Director,
Nicholas J. Jouriles, MD EMS & International Disaster Medical Sciences Fellowship,
Professor and Chair, Department of Emergency Medicine, Director of Public Health Preparedness, University of
Northeast Ohio Medical University, Rootstown, Ohio; Chair, California, Irvine School of Medicine, Irvine, California;
Department of Emergency Medicine, Cleveland Clinic EMS Medical Director, County of San Diego Health &
Akron, GeneralAkron, Ohio; Past President, American Human Services Agency, San Diego, California
College of Emergency Physicians, Dallas, Texas
Joshua M. Kosowsky, MD
Amy H. Kaji, MD, PhD Attending Physician, Department of Emergency Medicine,
Associate Professor, Emergency Medicine, David Geffen School Brigham and Women’s Hospital; Assistant Professor,
of Medicine at UCLA; Vice Chair of Academic Affairs, Department of Emergency Medicine, Harvard Medical
Department of Emergency Medicine, Harbor-UCLA, School, Boston, Massachusetts
Long Beach, California
Michael C. Kurz, MD, MS, FACEP
Tarina Lee Kang, MD Associate Professor, Department of Emergency Medicine,
Associate Professor of Emergency Medicine, LAC USC Medical University of Alabama School of Medicine, Birmingham,
Center, Keck School of Medicine, Los Angeles, California Alabama
Contributors xiii

Thomas Kwiatkowski, MD Mark D. Lo, MD


Assistant Dean and Professor, Emergency Medicine Basic Department of Pediatric Emergency Medicine, Seattle Children’s
Sciences, Hofstra Northwell School of Medicine, Hempstead, Hospital, Seattle, Washington
New York; Attending Physician, Emergency Medicine, Long
Island Jewish Medical Center, New Hyde Park, New York; Sharon E. Mace, MD, FACEP, FAAP
Attending Physician, Emergency Medicine, North Shore Professor of Emergency Medicine, Cleveland Clinical Lerner
University Hospital, Manhasset, New York College of Medicine at Case Western Reserve University,
Cleveland, Ohio
Nicole Lazarciuc, MD, MPH
Assistant Clinical Professor, Mount Sinai Icahn School of Gerald E. Maloney, Jr, DO
Medicine, New York, New York Attending Physician, Emergency Medicine, MetroHealth Medical
Center; Assistant Professor, Emergency Medicine, Case
Andrew W. Lee, MD Western Reserve University, Cleveland, Ohio
Associate Vice Chair, Operations; Assistant Professor,
Department of Emergency Medicine, University of Patrick J. Maloney, MD
Wisconsin, Madison, Wisconsin Medical Director, Pediatric Emergency Services, Emergency
Medicine, Mission Hospital, Asheville, North Carolina
Christopher C. Lee, MD
Assistant Professor, Stony Brook University, Stony Brook, Rebekah Mannix, MD, MPH
New York Assistant Professor, Pediatrics, Harvard Medical School;
Attending Physician, Emergency Medicine, Boston Children’s
Jeffrey E. Lee, MD Hospital, Boston, Massachusetts
Assistant Professor, Program Director, Ophthalmology, UC San
Diego, San Diego, California Catherine A. Marco, MD
Professor, Emergency Medicine, Wright State University
Charles Lei, MD Boonshoft School of Medicine; Attending Physician,
Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Miami Valley Hospital, Dayton, Ohio
Emergency Medicine, Vanderbilt University Medical Center,
Nashville, Tennesee Marc L. Martel, MD
Faculty, Department of Emergency Medicine, Hennepin County
Michael D. Levine, MD Medical Center; Associate Professor, Department of
Department of Emergency Medicine, Division of Medical Emergency Medicine, University of Minnesota, Minneapolis,
Toxicology, Assistant Professor, Department of Emergency Minnesota
Medicine, Section of Medical Toxicology, University of
Southern California, Los Angeles, California Ryanne J. Mayersak, MS, MD
Assistant Professor, Assistant Residency Director, Department of
Phillip D. Levy, MD, MPH Emergency Medicine, Oregon Health & Science University,
Professor and Associate Chair for Research, Department of Portland, Oregon
Emergency Medcicine, Wayne State University, Detroit,
Michigan Maryann Mazer-Amirshahi, PharmD, MD, MPH
Assistant Professor, Emergency Medicine, MedStar Washington
Christopher S. Lim, MD Hospital Center; Assistant Professor of Emergency Medicine,
Assistant Professor, Department of Emergency Medicine, Rush Georgetown University School of Medicine, Washington, DC
University Medical Center, Chicago, Illinois
Maureen McCollough, MD, MPH
Daniel Lindberg, MD Associate Professor of Emergency Medicine, USC Keck School
Associate Professor, Emergency Medicine and Pediatrics, of Medicine, Department of Emergency Medicine,
University of Colorado, Denver, Colorado Oliveview-UCLA Medical Center, Sylmar, California

Judith A. Linden, MD Taylor McCormick, MD, MS


Associate Professor and Vice Chair for Education, Emergency Emergency Medicine Physician, Denver Health Medical Center,
Medicine, Boston University, Boston Medical Center, Boston, Denver, Colorado; Instructor, Department of Emergency
Massachusetts Medicine, University of Colorado School Of Medicine,
Aurora, Colorado
Ari M. Lipsky, MD, PhD
Attending Physician, Emergency Department, Clear Lake Michael T. McCurdy, MD
Regional Medical Center, Webster, Texas; Research Director, Associate Professor, Departments of Medicine (Division of
Emergency Medicine, Rambam Health Care Campus, Haifa, Pulmonary and Critical Care) and Emergency Medicine,
Israel University of Maryland School of Medicine, Baltimore,
Maryland
xiv Contributors

Nathanael J. McKeown, DO Gregory J. Moran, MD


Assistant Professor, Department of Emergency Medicine, Professor, Department of Clinical Emergency and Medicine,
Oregon Health and Science University; Attending Physician, David Geffen School of Medicine at UCLA, Los Angeles,
Department of Emergency Medicine, Portland VA Medical California; Department of Emergency Medicine and Division
Center, Portland, Oregon of Infectious Diseases, Olive View-UCLA Medical Center,
Sylmar, California
Jeffry McKinzie, MD
Assistant Professor, Emergency Medicine; Assistant Professor, Raveendra S. Morchi, MD
Pediatrics, Vanderbilt University, Nashville, Tennessee Associate Professor in Emergency Medicine, Department of
Emergency Medicine, Harbor- UCLA Medical Center,
Kemedy K. McQuillen, MD Torrance, California
Attending Physician, Emergency Medicine, St. Mary’s Regional
Medical Center, Lewiston, Maine Robert L. Muelleman, MD
Professor and Chair, Department of Emergency Medicine,
Timothy J. Meehan, MD, MPH University of Nebraska Medical Center, Omaha, Nebraska
Assistant Clinical Professor, Emergency Medicine and Medical
Toxicology, University of Illinois Hospital and Health Science Brittany Lee Murray, MD
System, Chicago, Illinois Assistant Professor, Division of Pediatric Emergency Medicine,
Emory University School of Medicine, Atlanta, Georgia;
David A. Meguerdichian, MD Honorary Lecturer, Emergency Medicine Department,
Instructor of Emergency Medicine, Harvard Medical School; Muhimbili University of Health and Allied Sciences, Dar es
Brigham and Women’s Hospital, Boston, Massachusetts Salaam, Tanzania

Frantz R. Melio, MD Mark B. Mycyk, MD


Director of Physician Outreach and Strategic Development, Attending Physician, Emergency Medicine, Cook County
University of New Mexico Medical Group, University of New Hospital; Research Director, Toxikon Consortium, Chicago,
Mexico Health System, Albuquerque, New Mexico Illinois

Felipe Teran Merino, MD Joshua Nagler, MD, MHPEd


Academic Chief Resident, Instructor, Department of Emergency Assistant Professor, Pediatrics and Emergency Medicine,
Medicine, Icahn School of Medicine at Mount Sinai, New Harvard Medical School; Fellowship Director, Division of
York, New York Emergency Medicine, Boston Children’s Hospital, Boston,
Massachusetts
William J. Meurer, MD, MS
Associate Professor, Department of Emergency Medicine, Sidhant Nagrani, MD
Associate Professor, Department of Neurology, University of Director of Residency Simulation, Emergency Medicine, Emory
Michigan, Ann Arbor, Michigan School of Medicine, Atlanta, Georgia

Nathan W. Mick, MD Anthony M. Napoli, MD


Director, Pediatric Emergency Medicine, Department of Associate Professor of Emergency Medicine, Department of
Emergency Medicine, Maine Medical Center, Portland, Maine Emergency Medicine, The Warren Alpert Medical School at
Brown University, Providence, Rhode Island
James R. Miner, MD
Chief of Emergency Medicine, Hennepin County Medical Lewis S. Nelson, MD
Center; Professor of Emergency Medicine, University of Professor and Chair, Department of Emergency Medicine, New
Minnesota, Minneapolis, Minnesota Jersey Poison Information and Education System, Rutgers
New Jersey Medical School, Newark, New Jersey
Alicia B. Minns, MD
Assistant Clinical Professor of Emergency Medicine, Emergency Michael E. Nelson, MD, MS
Medicine, UCSD, San Diego, California Attending Physician, Emergency Medicine, NorthShore
University Health System, Evanston, Illinois; Attending
Jessica Monas, MD Physician, Emergency Medicine, Toxicology, Cook County
Hospital Stroger), Chicago, Illinois
Clinical Assistant Professor, Emergency Medicine, University of
Arizona College of Medicine, Phoenix, Arizona
Robert W. Neumar, MD, PhD
Andrew A. Monte, MD Professor and Chair, Department of Emergency Medicine,
University of Michigan Health System, Ann Arbor, Michigan
Associate Professor, Department of Emergency Medicine,
University of Colorado School of Medicine, Aurora,
Colorado Kim Newton, MD
Associate Professor, Emergency Medicine, USC, Keck School of
Gregory P. Moore, MD, JD Medicine, Los Angeles, California
Faculty Emergency Medicine Residency, Madigan Army Medical
Center, Tacoma, Washington
Contributors xv

Thomas Nguyen, MD Daniel J. Pallin, MD, MPH


Associate Program Director, Emergency Medicine, Mount Sinai Research Director, Department of Emergency Medicine,
Beth Israel, New York, New York Brigham and Women’s Hospital; Assistant Professor,
Department of Emergency Medicine, Harvard Medical
James R. Nichols III, DO School, Boston, Massachusetts
Assistant Professor, Assistant Director of Emergency Ultrasound,
Emergency Medicine, Univeristy of Mississippi Medicial Linda Papa, MD, MSc
Center, Jackson, Mississippi Director of Academic Clinical Research, Professor of Emergency
Medicine, Orlando Regional Medical Center; Professor,
James T. Niemann, MD Department of Medicine, University of Central Florida,
Professor of Medicine, UCLA School of Medicine, Department Orlando, Florida; Adjunct Professor, Emergency Medicine,
of Emergency Medicine, Harbor-UCLA Medical Center, University of Florida, Gainesville, Florida; Adjunct Professor,
Torrance, California Neurology and Neurosurgery, McGill University, Montreal,
Quebec, Canada
Jenna K. Nikolaides, MD, MA
Medical Toxicology Fellow, Toxikon Consortium, Chicago, Ram Parekh, BA, MD
Illinois Assistant Professor, Emergency Department, Icahn School of
Medicine at Mount Sinai, New York, New York; Attending
Kimberly Nordstrom, MD, JD Physician, Emergency Department, Elmhurst Hospital
Center, Elmhurst, New York
Medical Director, Psychiatric Emergency Services, Department
of Psychiatry, Denver Health Medical Center, Denver,
Colorado; Assistant Professor, Department of Psychiatry, Asad E. Patanwala, PharmD
University of Colorado Anschutz Medical Campus, Aurora, Associate Professor, Pharmacy Practice and Science, The
Colorado University of Arizona, Tucson, Arizona

Richard M. Nowak, MD, MBA David A. Peak, MD


Emergency Medicine, Henry Ford Health System; Professor, Assistant Residency Director, Harvard Affiliated Emergency
Emergency Medicine, Wayne State Medical School, Detroit, Medicine Residency, Emergency Medicine, Massachusetts
Michigan; Clinical Associate Professor, Emergency Medicine, General Hospital; Assistant Professor, Emergency Medicine
University of Michigan Medical School, Ann Arbor, Michigan (Surgery), Harvard Medical School, Boston, Massachusetts

John F. O’Brien, BS, MD Ryan Anthony Pedigo, MD


Attending Physician, Department of Emergency Medicine, Director of Undergraduate Medical Education, Department of
Orlando Regional Medical Center; Associate Clinical Emergency Medicine, Harbor-UCLA Medical Center,
Professor, Department of Emergency Medicine, University of Torrance, California; Assistant Professor of Medicine, David
Central Florida, Orlando, Florida; Associate Clinical Geffen School of Medicine at UCLA, Los Angeles, California
Professor, Department of Surgery, University of Florida,
Gainesville, Florida Debra Perina, MD
Professor, Division Director, Prehospital Care, Regional Quality
Adedamola A. Ogunniyi, MD Director, Emergency Medicine, University of Virginia,
Faculty, Department of Emergency Medicine, Director, Process Charlottesville, Virginia
and Quality Improvement Program, Harbor-UCLA Medical
Center, Torrance, California Andrew D. Perron, MD
Professor and Residency Program Director, Department of
Kelly P. O’Keefe, MD Emergency Medicine, Maine Medical Center, Portland, Maine
Program Director, Emergency Medicine, Unversity of South
Florida-Tampa General Hospital, Tampa, Florida Shawna J. Perry, MD
Associate Professor, Emergency Medicine, University of Florida
Edward Joseph Otten, MD College of Medicine-Jacksonville, Jacksonville, Florida;
Professor of Emergency Medicine and Pediatrics, Director, Honorary Associate Professor, CPQI, Department of
Division of Toxicology, University of Cincinnati College of Industrial Engineering, University of Wisconsin-Madison,
Medicine, Cincinnati, Ohio Madison, Wisconsin

Leslie C. Oyama, MD Michael A. Peterson, MD


Associate Clinical Professor, Emergency Medicine, University of Assistant Professor, Department of Medicine, David Geffen
California, San Diego, San Diego, California School of Medicine at UCLA, Los Angeles, California;
Director, Adult Emergency Department, Department of
Patricia Padlipsky, MD, MS Emergency Medicine, Harbor-UCLA Medical Center,
Torrance, California
Associate Clinical Professor of Pediatrics, David Geffen School
of Medicine, University of California at Los Angeles, Los
Angeles, California; Director, Pediatric Emergency
Department, Harbor-UCLA Medical Center, Torrance,
California
xvi Contributors

James A. Pfaff, MD Robert F. Reardon, MD


Assistant Professor, Department of Military and Emergency Professor, Department of Emergency Medicine, University of
Medicine, Uniformed Services University of the Health Minnesota; Faculty Physician, Department of Emergency
Sciences, Bethesda, Maryland; Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis,
Medicine, San Antonio Military Medical Center, Staff Minnesota
Physician, San Antonio Uniformed Services Health
Education Consortium, San Antonio Military Medical David B. Richards, MD, FACEP
Centers, Fort Sam Houston, Texas Assistant Professor, Department of Emergency Medicine,
University of Colorado School of Medicine; Director,
Camiron L. Pfennig, MD, MHPE Medical Student and Intern Clerkship, Department of
Associate Professor, Emergency Medicine, University of South Emergency Medicine, Denver Health Medical Center, Denver,
Carolina Greenville; Residency Program Director, Emergency Colorado
Medicine, Greenville Health System, Greenville, South
Carolina Ralph J. Riviello, MD, MS
Professor and Vice Chair of Clinical Operations, Emergency
Melissa Platt, MD Medicine, Drexel University College of Medicine; Medical
Associate Professor, Emergency Medicine, University of Director, Philadelphia Sexual Assault Response Center,
Louisville, Louisville, Kentucky Philadelphia, Pennsylvania

Charles V. Pollack, Jr., MA, MD Daniel W. Robinson, MD


Professor, Emergency Medicine, Sidney Kimmel College of Assistant Professor of Medicine, Section of Emergency
Medicine; Associate Provost, Associate Dean for Continuing Medicine, Department of Medicine, University of Chicago
Medical Education, Thomas Jefferson University, Medicine and Biological Sciences, Chicago, Illinois
Philadelphia, Pennsylvania
Howard Rodenberg, MD, MPH
Trevor R. Pour, BA, MD Emergency Physician, Stormont-Vail HealthCare, Topeka,
Assisstant Residency Program Director, Department of Kansas; Physician Advisor, Clinical Documentation
Emergency Medicine, Mount Sinai Hospital, New York, Improvement, Baptist Health of Northeast Florida,
New York Jacksonville, Florida

Timothy G. Price, MD Chad E. Roline, MD


Associate Professor, Emergency Medicine, University of Department of Emergency Medicine, North Memorial Health
Louisville, Louisville, Kentucky Care, Robbinsdale, Minnesota

Michael A. Puskarich, MD Genie E. Roosevelt, MD, MPH


Associate Professor, Research Director, University of Mississippi Associate Professor, Emergency Medicine, Denver Health
Medical Center, Jackson, Mississippi; Emergency Medicine, Medical Center, Denver, Colorado
Carolinas Medical Center, Charlotte, North Carolina
Emily Rose, MD
Tammie E. Quest, MD Assistant Professor of Clinical Emergency Medicine, Department
Professor, Emory University School of Medicine, Department of of Emergency Medicine, LA County + USC Medical Center,
Emergency Medicine; Director, Emory Palliative Care Center; Keck School of Medicine of the University of Southern
Chief, Department of Veterans Affairs, Hospice and Palliative California, Los Angeles, California
Medicine, Atlanta, Georgia
Gabriel Rose, DO
Elaine Rabin, MD Clinical Instructor, Department of Emergency Medicine, Mount
Icahn School of Medicine at Mount Sinai, New York, New York Sinai St. Luke’s-Mount Sinai West Hospitals, New York, New
York
Ali S. Raja, MD, MBA, MPH
Vice Chairman, Department of Emergency Medicine, Nicholas G.W. Rose, MD, PhD, FRCPC, Dip Sports Med
Massachusetts General Hospital; Associate Professor of (CASEM)
Emergency Medicine and Radiology, Harvard Medical Clinical Assistant Professor, Department of Emergency
School, Boston, Massachusetts Medicine,University of British Columbia, Vancouver, British
Columbia, Canada
Rama B. Rao, MD
Assistant Professor, Chief, Division of Medical Toxicology, Tony Rosen, MD, MPH
Department of Emergency Medicine, New York Presbyterian Instructor in Medicine, Division of Emergency Medicine, Weill
Hospital, Weill Cornell Medicine, New York, New York Cornell Medical College, New York, New York

Neha P. Raukar, MD, MS Anne-Michelle Ruha, MD


Assistant Professor, Emergency Medicine, Warren Alpert Medical Fellowship Director, Medical Toxicology, Banner Good
School of Brown University; Attending Physician, Emergency Samaritan Medical Center, Phoenix, Arizona
Medicine, Rhode Island-Miriam Hospital; Director,
Emergency Medicine, Center for Sports Medicine,
Providence, Rhode Island
Contributors xvii

Christopher S. Russi, DO Rachel Semmons, MD


Chair, Division of Community Emergency Medicine, Associate Education Director, Senior Emergency Medicine
Department of Emergency Medicine; Assistant Professor of Clerkship Director, Associate Fellowship Director EMS
Emergency Medicine, Mayo Clinic, Rochester, Minnesota Fellowship, Emergency Medicine, University of South
Florida; Associate Department Director, Emergency
Bisan A. Salhi, MD Medicine, Tampa General Hospital, Tampa, Florida
Assistant Professor, Emergency Medicine, Emory University,
Atlanta, Georgia Joseph Sexton, MD, FACEP
Attending Physician, Emergency Medicine, Lehigh Valley Health
Arthur B. Sanders, MD, MHA Network, Allentown, Pennsylvania
Professor, Emergency Medicine, University of Arizona, Tucson,
Arizona Nathan I. Shapiro, MD, MPH
Vice Chairman of Emergency Medicine Research, Department
Genevieve Santillanes, MD of Emergency Medicine, Beth Israel Deaconess Medical
Assistant Professor, Emergency Medicine, Keck School of Center, Boston, Massachusetts
Medicine of the University of Southern California, Los
Angeles, California Dag Shapshak, MD
Associate Professor, Department of Emergency Medicine,
Richard J. Scarfone, MD University of Alabama, Birmingham, Birmingham, Alabama
Associate Professor, Pediatrics, Perelman School of Medicine at
the University of Pennsylvania; Attending Physician, Division Peter Shearer, MD
of Emergency Medicine, Children’s Hospital of Philadelphia, Medical Director, Emergency Medicine, Mount Sinai Hospital,
Philadelphia, Pennsylvania New York, New York

Carl H. Schultz, MD, FACEP Sanjay N. Shewakramani, MD


Professor of Emergency Medicine and Public Health, Director of Assistant Professor, Department of Emergency Medicine,
Research, Center for Disaster Medical Sciences; Director, University of Cincinnati, Cincinnati, Ohio
EMS and Disaster Medical Sciences Fellowship, University of
California Irvine School of Medicine, Irvine, California; Lee W. Shockley, MD, MBA
Director, Disaster Medical Services, Department of Attending Emergency Physician, Emergency Medicine,
Emergency Medicine, University of California Irvine Medical CarePoint; Professor, Emergency Medicine, The University of
Center, Orange, California Colorado School of Medicine, Denver, Colorado

Jeremiah D. Schuur, MD, MHS Jan M. Shoenberger, MD


Chief, Division of Health Policy Translation, Department of Residency Director, Emergency Medicine, Los Angeles County +
Emergency Medicine; Vice Chair, Quality and Safety Clinical USC Medical Center; Associate Professor of Clinical
Affairs, Department of Emergency Medicine, Brigham and Emergency Medicine, Emergency Medicine, Keck School of
Women’s Hospital; Assistant Professor, Department of Medicine of USC, Los Angeles, California
Emergency Medicine, Harvard Medical School, Boston,
Massachusetts Barry C. Simon, MD
Chairman, Department of Emergency Medicine, Highland
Halden F. Scott, MD General Hospital; Professor of Emergency Medicine,
Assistant Professor, Pediatrics and Emergency Medicine, University of California San Francisco, San Francisco,
University of Colorado School of Medicine; Attending California
Physician, Section of Emergency Medicine, Children’s
Hospital Colorado, Aurora, Colorado Adam J. Singer, MD
Professor and Vice Chairman, Emergency Medicine, Stonybrook
Raghu Seethala, MD University, Stony Brook, New York
Instructor, Emergency Medicine, Harvard Medical School;
Emergency Medicine, Brigham and Women’s Hospital, Aaron B. Skolnik, MD
Boston, Massachusetts
Assistant Medical Director, Banner Good Samaritan Poison and
Drug Information Center, Department of Medical
Jeffrey A. Seiden, MD Toxicology, Banner-University Medical Center Phoenix;
Associate Medical Director, Pediatric Emergency Medicine, Clinical Assistant Professor, Department of Emergency
CHOP at Virtua, Voorhees, New Jersey Medicine, University of Arizona College of Medicine-
Phoenix, Phoenix, Arizona
Todd A. Seigel, MD
Staff Physician, Emergency Medicine and Critical Care Corey M. Slovis, MD
Medicine, Kaiser Permanente, Oakland Medical Center, Chairman, Emergency Medicine, Vanderbilt University Medical
Oakland, California Center; Medical Director, Nashville Fire Department; Medical
Director, Nashville International Airport, Nashville,
Tennessee
xviii Contributors

Clay Smith, MD Morsal Tahouni, MD


Assistant Professor of Emergency Medicine, Internal Medicine, Assistant Medical Director, Department of Emergency Medicine,
and Pediatrics, Emergency Medicine, Vanderbilt University Boston Medical Center; Assistant Professor of Medicine,
Medical Center, Nashville, Tennessee Department of Emergency Medicine, Boston University
School of Medicine, Boston, Massachusetts
Kurt A. Smith, MD, FACEP
Assistant Professor, Emergency Medicine, Vanderbilt University, Sukhjit S. Takhar, MD
Nashville, Tennessee Instructor, Medicine (Emergency Medicine), Harvard Medical
School; Attending Physician, Emergency Medicine, Brigham
David C. Snow, MD, MSc and Women’s Hospital, Boston, Massachusetts
Assistant Residency Director, Assistant Professor of Emergency
Medicine, Emergency Medicine, University of Illinois at Nelson Tang, MD, FACEP
Chicago, Chicago, Illinois Associate Professor, Emergency Medicine, Johns Hopkins
Uniiversity School of Medicine; Director, Division of Special
Peter E. Sokolove, MD Operations, Johns Hopkins Medical Institutions; Chief
Professor and Chair, Department of Emergency Medicine, Medical Officer, Center for Law Enforcement Medicine,
University of California San Francisco School of Medicine, Baltimore, Maryland
San Francisco, California; Sacramento
Todd Andrew Taylor, MD
David M. Somand, MD Assistant Professor, Emergency Medicine, Emory University
Assistant Professor, Department of Emergency Medicine, School of Medicine, Atlanta, Georgia
University of Michigan Hospital, Ann Arbor, Michigan
James L. Thea, MD
Benjamin Squire, MD, MPH Associate Professor of Emergency Medicine, Emergency
Clinical Instructor of Medicine, David Geffen School of Medicine, Boston University School of Medicine, Boston,
Medicine at UCLA, Department of Emergency Medicine, Massachusetts
Harbor-UCLA Medical Center, Torrance, California
Jillian L. Theobald, MD, PhD
Stephen C. Stanfield, M.Arch, MD Assistant Professor, Department of Emergency Medicine,
Emergency Medicine, Regions Hospital, St. Paul, Minnesota Medical College of Wisconsin, Milwaukee, Wisconsin

Dana A. Stearns, MD Molly E.W. Thiessen, MD


Associate Physician, Department of Emergency Medicine, Assistant Emergency Ultrasound Director, Emergency Medicine,
Massachusetts General Hospital; Assistant Profesor of Denver Health Medical Center, Denver, Colorado; Assistant
Emergency Medicine, Associate Advisory Dean, William Professor, Emergency Medicine, University of Colorado
Bosworth Castle Society, Harvard Medical School, Boston, School of Medicine, Aurora, Colorado
Massachusetts
J. Jeremy Thomas, MD
Michael E. Stern, MD Associate Professor, Medical Director, University Emergency
Assistant Professor of Clinical Medicine, Division of Emergency Department, Emergency Medicine, University of Alabama at
Medicine, Weill Cornell Medical Center, New York, New York Birmingham, Birmingham, Alabama

Brian A. Stettler, MD Stephen H. Thomas, MD, MPH


Assistant Professor of Clinical Medicine, Division of Emergency Professor and Chair, Hamad Medical Corporation, Department
Medicine, University of Cincinnati, Cincinnati, Ohio of Emergency Medicine; Chief of Service, Hamad General
Hospital Emergency Department, Weill Cornell Medical
Michael B. Stone, MD College in Qatar, Doha, Qatar
Chief, Division of Emergency Ultrasound, Emergency Medicine,
Brigham and Women’s Hospital, Boston, Massachusetts Trevonne M. Thompson, MD, FACEP, FACMT
Associate Professor, Emergency Medicine and Medical
Reuben J. Strayer, MD Toxicology, Director, Division of Medical Toxicology,
Department of Emergency Medicine, University of Illinois at
Department of Emergency Medicine, Icahn School of Medicine at
Chicago, Chicago, Illinois
Mount Sinai, NYU School of Medicine, New York, New York

Amita Sudhir, MD Carrie D. Tibbles, MD


Associate Director, Graduate Medical Education, Beth Israel
Assistant Professor, Emergency Medicine, University of Virginia,
Deaconess Medical Center; Associate Program Director,
Charlottesville, Virginia
Harvard Affiliated Emergency Medicine Residency; Assistant
Professor of Medicine, Harvard Medical School, Boston,
Ramin R. Tabatabai, MD Massachusetts
Assistant Professor of Clinical Emergency Medicine, Keck
School of Medicine of the University of Southern California; Glenn F. Tokarski, MD
Assistant Program Director, Department of Emergency
Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
Medicine, LAC + USC Medical Center, Los Angeles,
California
Contributors xix

Veronica Vasquez, MD David T. Williams, MD


Assistant Professor, Department of Emergency Medicine, Attending Staff Physician, Department of Emergency Medicine,
University of Southern California, LAC + USC Medical Maui Memorial Medical Center, Wailuku, Hawaii
Center, Los Angeles, California
Craig A. Williamson, MD
David A. Wacker, MD, PhD Assistant Professor, Neurosurgery, Assistant Professor,
Assistant Professor, Department of Medicine (Division of Neurology, University of Michigan, Ann Arbor, Michigan
Pulmonary, Allergy, Critical Care, and Sleep Medicine),
University of Minnesota Medical School, Minneapolis, Matthew D. Wilson, MD
Minnesota Attending Physician, Emergency Medicine, Washington Hospital
Center; Assistant Professor of Emergency Medicine,
Laura Walker, MD Georgetown University School of Medicine, Washington, DC
Clinical Instructor, Emergency Medicine, Mayo Medical School,
Rochester, Minnesota Adria Ottoboni Winter, MD
Assistant Clinical Professor, Department of Emergency
Ron M. Walls, MD Medicine, Kern Medical/UCLA, Bakersfield, California
Executive Vice President and Chief Operating Officer, Brigham
Health; Neskey Family Professor of Emergency Medicine, Allan B. Wolfson, MD, FACEP, FACP
Harvard Medical School, Boston, Massachusetts Professor of Emergency Medicine, Vice Chair for Education,
Department of Emergency Medicine, University of
George Sam Wang, MD Pittsburgh, Pittsburgh, Pennsylvania
Assistant Professor of Pediatrics, Department of Pediatrics,
Section of Emergency Medicine and Medical Toxicology, Andrea W. Wu, MD, MMM, FACEP
Children’s Hospital Colorado, University of Colorado Core Faculty, Department of Emergency Medicine; Director,
Anschutz Medical Campus, Aurora, Colorado Adult Emergency Department, Harbor-UCLA Medical
Center, Torrance, California
Matthew A. Waxman, MD, DTM and H
Associate Clinical Professor, Department of Emergency Donald M. Yealy, MD
Medicine and Department of Medicine, Olive View-UCLA Professor and Chair, Emergency Medicine, University of
Medical Center, Los Angeles, California Pittsburgh, Pittsburgh, Pennsylvania

Robert L. Wears, MD, MS, PhD Ken Zafren, MD, FAAEM, FACEP, FAWM
Professor, Emergency Medicine, University of Florida, Emergency Programs Medical Director, State of Alaska,
Jacksonville, Florida; Visiting Professor, Clinical Safety Anchorage, Alaska; Clinical Professor, Department of
Research Unit, Imperial College London, London, England Emergency Medicine, Stanford University Medical Center,
Stanford, California; Staff Emergency Physician, Alaska
Lori Weichenthal, MD Native Medical Center, Anchorage, Alaska
Professor of Clinical Emergency Medicine, Emergency Medicine,
UCSF Fresno, Fresno, California Brian J. Zink, MD
Professor and Chair, Emergency Medicine, Alpert Medical
Katherine Welker, MD, MPH School of Brown University; Physician-in-Chief, Emergency
Attending Physician, Department of Emergency Medicine, San Medicine, Rhode Island, Newport and The Miriam Hospitals,
Diego, California; Toxicology Fellowship, Toxikon Providence, Rhode Island
Consortium, Cook County Hospital, Chicago, Illinois
Leslie S. Zun, MD, MBA
Matthew A. Wheatley, MD Professor and Chair, Emergency Medicine, Rosalind Franklin
Assistant Professor, Emergency Medicine, Emory University University of Medicine and Science-Chicago Medical School,
School of Medicine, Atlanta, Georgia North Chicago, Illinois; System Chair, Emergency Medicine,
Sinai Health System, Chicago, Illinois
John M. Wightman, MD, MA, FACEP
Director, Human Research Protection Program, 711th Human
Performance Wing, Air Force Research Laboratory, Wright-
Patterson Air Force Base, Ohio; Adjunct Professor,
Department of Military and Emergency Medicine, F. Edward
Hébert School of Medicine, Uniformed Services University,
Bethesda, Maryland; Clinical Professor, Department of
Emergency Medicine, Boonshoft School of Medicine, Wright
State University, Dayton, Ohio
Preface to the Ninth Edition
When we began planning for this ninth edition, we challenged make specific recommendations, and give the reader clear indica-
ourselves to make substantial and meaningful improvements to a tions of the preferred actions. This makes the book much more
book that has become the trusted standard in our field. With immediately relevant for emergency clinicians. We recognize that
broad and rapid changes occurring in health care and information emergency medicine is practiced by specialist emergency physi-
sciences, we recognized that relevance is not an accidental or cians, other physicians, residents and other trainees, and a variety
passive concept. To advance in relevance and consolidate the of nonphysician practitioners, so were careful to ensure that we
book’s position as the defining reference in our specialty, we care- are addressing all these groups with the same concise, highest
fully and deliberately undertook bold changes that we know make quality information and recommendations.
the book at once fresh, directive, and current in a way we have We revisited page counts for every chapter, adjusting alloca-
never before dared. tions where indicated, and added new chapters on several impor-
First, we created a substantially enhanced role for our editors, tant topics. We focused anew on consistency and redundancy,
one that would demand a great deal more of their time, creativity, enhancing the former and minimizing the latter. We moved
and energy. This helped us build a substantially different team some chapters to online access only, allowing us to add new topics
of editors, a perfectly balanced blend of those with great experi- of interest, such as drug therapy for older patients, and have
ence with prior editions and those who would bring new ideas provided a rich array of dynamic videos and images, especially in
and challenge our assumptions. Ron Walls was asked to serve as emergency ultrasound. We substantially expanded and reorganized
Editor-in-Chief, with Bob Hockberger in his long-standing role as the pediatric emergency medicine section, introducing dedicated
senior editor. Marianne Gausche-Hill, a highly respected academic pediatric chapters on airway management, procedural sedation,
emergency physician with service as editor on four previous and drug therapy. We introduced significant new material on
editions, stepped up to complete our senior editorial ranks. At emergencies in the pregnant woman, the patient with cancer, and
the editor level, Dr. Andy Jagoda returns and is joined by six a variety of other highly important clinical conditions. And, in
brilliant new editors drawn from academic programs from coast every possible case, we insisted on adherence to referencing and
to coast—Drs. Katherine Bakes, Jill Baren, Timothy Erickson, Amy writing requirements, a focus on relevant directive information,
Kaji, Michael VanRooyen, and Richard Zane. This dynamic and and appropriate use of prose and illustrations to provide the
innovative editorial team has dramatically redrawn our text’s perfect balance of depth, breadth, and ready accessibility.
blueprint by preserving what has served our readers the best, We are enormously proud of the result, a different, more read-
such as well-written discussions of the pathophysiologic basis of able “Rosen,” preserving the gravitas earned over 30 years as the
illness and injury, while moving in entirely new directions in most important book in our specialty while embracing the
providing pithy, clear, and succinct recommendations for diagno- modern era of emergency medicine practice and research and an
sis and treatment. entirely new generation of learners and practitioners. For those
We collectively determined that all references prior to 2010 who have owned prior editions, we appreciate your loyalty over
have been sufficiently long in the public domain that they no so many years and hope to reward it with a significantly improved
longer warrant citation. The infrequent exception to this is for and useful companion for your continuing learning and practice
guidelines that were issued in 2007 or later and have not been of this great specialty. For our newer readers, welcome, and thank
reissued or supplanted since. Strict adherence to our referenc- you for inspiring us to make significant changes to an iconic and
ing policy required authors to diligently provide well-researched timeless part of our academic heritage.
and detailed updates to their chapter content, based on only the
most recent and relevant medical literature. In cases in which Ron M. Walls
the literature is controversial or unclear, we have used the Robert S. Hockberger
combined experience and expertise of our authors and editors Marianne Gausche-Hill
to present cogent analyses of diagnostic and treatment options,

xxi
How This Medical Textbook Should Be Viewed by the Practicing Clinician
and Judicial System
The editors and authors of this text strongly believe that the complex practice of medicine, vagaries
of human diseases, unpredictability of pathologic conditions, and functions, dysfunctions, and
responses of the human body cannot be defined, explained, or rigidly categorized by any written
document. Therefore, it is neither the purpose nor intent of our textbook to serve as an authoritative
source on any medical condition, treatment plan, or clinical intervention, nor should our textbook be used
to rigorously define a standard of care that should be practiced by all clinicians.
Our written word provides the physician with a literature-referenced database and a reasonable
clinical guide combined with practical suggestions from individual experienced practitioners. We offer
a general reference source and clinical road map on a variety of conditions and procedures that may
confront emergency clinicians who are experienced in emergency medicine practice. This text cannot
replace physician judgment, cannot describe every possible aberration, nuance, clinical scenario,
or presentation, and cannot define rigid standards for clinical actions or procedures. Every medical
encounter must be individualized, and every patient must be approached on a case-by-case basis. No
complex medical interaction can possibly be reduced to the written word. The treatments, procedures,
and medical conditions described in this text do not constitute the total expertise or knowledge base
expected to be possessed by all emergency clinicians. Finally, many of the described complications and
adverse outcomes associated with implementing or withholding complex medical and surgical inter-
ventions may occur, even when every aspect of the intervention has been standard or performed
correctly.

The editors and authors of Rosen’s Emergency Medicine:


Concepts and Clinical Practice, Ninth Edition
SECTION ONE
Critical Management Principles
CHAPTER 1

Airway
Calvin A. Brown III | Ron M. Walls

PRINCIPLES Failure of Ventilation or Oxygenation

Background Gas exchange, both oxygenation and removal of carbon dioxide,


is required for vital organ function. Ventilatory failure that is not
Airway management is the cornerstone of resuscitation and is a reversible by clinical means or persistent hypoxemia despite
defining skill for the specialty of emergency medicine. The emer- maximal oxygen supplementation is a primary indication for
gency clinician has primary airway management responsibility, intubation. This assessment is clinical and includes an evaluation
and all airway techniques lie within the domain of emergency of the patient’s general status, oxygen saturation by pulse oxim-
medicine. Although rapid sequence intubation (RSI) is the most etry, and ventilatory pattern. Continuous capnography also can
commonly used method for emergent tracheal intubation, emer- be helpful but is not essential if oximetry readings are reliable.
gency airway management includes various intubation techniques Arterial blood gases (ABGs) generally are not required to deter-
and devices, approaches to the difficult airway, and rescue tech- mine the patient’s need for intubation. In most cases, clinical
niques when intubation fails. assessment, including pulse oximetry with or without capnogra-
phy, and observation of improvement or deterioration in the
Anatomy, Physiology, and Pathophysiology patient’s clinical condition lead to a correct decision. ABG results
are rarely helpful, are time-consuming to obtain, and may be
The decision to intubate should be based on careful patient misleading, causing a false sense of security and delay in intubat-
assessment and appraisal of the clinical presentation with ing a deteriorating patient. If obtained, they should be interpreted
respect to three essential criteria: (1) failure to maintain or carefully in the context of the patient’s clinical status. Patients who
protect the airway; (2) failure of ventilation or oxygenation; and are clinically improving despite severe or apparently worsening
(3) the patient’s anticipated clinical course and likelihood of ABG alterations may not require intubation, whereas a rapidly
deterioration. tiring asthmatic may require intubation, even though ABG values
are only modestly disturbed.
Failure to Maintain or Protect the Airway The need for prolonged mechanical ventilation generally man-
dates intubation. An external mask device, continuous positive
A patent airway is essential for adequate ventilation and oxygen- airway pressure (CPAP) and bi-level positive airway pressure (BL-
ation. If a patient is unable to maintain a patent airway, the PAP), have all been used successfully to manage patients with
airway should be established by using airway maneuvers such as exacerbations of chronic obstructive pulmonary disease (COPD)
repositioning, chin lift, jaw thrust, or insertion of an oral or nasal and congestive heart failure, obviating the need for intubation (see
airway. Likewise, the patient must be able to protect against the Chapter 2) but, despite these advances, many patients who need
aspiration of gastric contents, which carries significant morbidity assisted ventilation or positive pressure to improve oxygenation
and mortality. Historically, the presence of a gag reflex has require intubation.1,2
been advocated as a reliable indicator of the patient’s ability to
protect the airway, but this has been definitively proven to be Anticipated Clinical Course
unreliable because the gag reflex is absent in 12% to 25% of
normal adults, and there is no evidence that its presence or Certain conditions indicate the need for intubation, even without
absence corresponds to airway protective reflexes or predicts the an immediate threat to airway patency or adequacy of ventilation
need for intubation. The patient’s ability to swallow or handle and oxygenation. These conditions are characterized by a moder-
secretions is a more reliable indicator of airway protection. The ate to high likelihood of predictable airway deterioration or the
recommended approach is to evaluate the patient’s level of con- need for intubation to facilitate a patient’s evaluation and treat-
sciousness, ability to phonate in response to voice command or ment. Intubation may be indicated relatively early in the course
query, which provides information about the integrity of the of certain overdoses. Although the patient initially may be protect-
upper airway and level of consciousness, and ability to manage his ing the airway and exchanging gas adequately, intubation is advis-
or her own secretions (eg, pooling of secretions in the orophar- able to guard against the strong likelihood of clinical deterioration,
ynx, absence of swallowing spontaneously or on command). In which can occur after the initial phase of care when the patient is
general, a patient who requires a maneuver to establish a patent no longer closely observed. A patient who has sustained signifi-
airway or who easily tolerates an oral airway requires intubation cant multiple traumatic injuries may require intubation, even
for airway protection, unless there is a temporary or readily if the patient is ventilating normally through a patent airway
reversible condition, such as an opioid overdose. and has adequate oxygen levels. For example, a multiple trauma
3
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no related content on Scribd:
22. Howe’s Victory of June 1, 1794[66]

[Prior to the engagement, the French fleet had met and was
convoying to port 180 vessels from America with food-stuffs of which
France was then in dire need. The British fleet encountered the
French 400 miles west of Ushant on May 28, and in the four days of
maneuvering and pursuit which followed, Howe displayed marked
energy and tactical skill. Though the French fleet was defeated in the
ensuing battle, it covered the escape of the convoy.—Editor.]
The French admiral on the evening of the 29th saw that he now
must fight, and at a disadvantage; consequently, he could not hope to
protect the convoy. As to save this was his prime object, the next best
thing was to entice the British out of its path. With this view he stood
away to the north-west; while a dense fog coming on both favored his
design and prevented further encounter during the two ensuing days,
throughout which Howe continued to pursue. In the evening of May
31 the weather cleared, and at daybreak the next morning the
enemies were in position, ready for battle, two long columns of ships,
heading west, the British twenty-five, the French again twenty-six
through the junction of the four vessels mentioned. Howe now had
cause to regret his absent six, and to ponder Nelson’s wise saying,
“Only numbers can annihilate.”
This time for maneuvering was past. Able tactician as he
personally was, and admirable as had been the direction of his efforts
in the two days’ fighting, Howe had been forced in them to realize
two things, namely, that his captains were, singly, superior in
seamanship, and their crews in gunnery, to the French; and again,
that in the ability to work together as a fleet the British were so
deficient as to promise very imperfect results, if he attempted any
but the simplest formation. To such, therefore, he resorted; falling
back upon the old, unskillful, sledge-hammer fashion of the British
navy. Arranging his ships in one long line, three miles from the
enemy, he made them all go down together, each to attack a specified
opponent, coming into action as nearly as might be at the same
instant. Thus the French, from the individual inferiority of the units
of their fleet, would be at all points over-powered. The issue justified
the forecast; but the manner of performance was curiously and
happily marked by Howe’s own peculiar phlegm. There was a long
summer day ahead for fighting, and no need for hurry. The order was
first accurately formed, and canvas reduced to proper proportions.
Then the crews went to breakfast. After breakfast, the ships all
headed for the hostile line, under short sail, the admiral keeping
them in hand during the approach as an infantry officer dresses his
company. Hence the shock from end to end was so nearly
simultaneous as to induce success unequalled in any engagement
conducted on the same primitive plan.
Picturesque as well as sublime, animating as well as solemn, on
that bright Sunday morning, was this prelude to the stern game of
war about to be played: the quiet summer sea stirred only by a breeze
sufficient to cap with white the little waves that ruffled its surface;
the dark hulls gently rippling the water aside in their slow advance, a
ridge of foam curling on either side of the furrow ploughed by them
in their onward way; their massive sides broken by two, or at times
three, rows of ports, whence, the tompions drawn, yawned the sullen
lines of guns, behind which, unseen, but easily realized by the
instructed eye, clustered the groups of ready seamen who served
each piece. Aloft swung leisurely to and fro the tall spars, which
ordinarily, in so light a wind, would be clad in canvas from deck to
truck, but whose naked trimness now proclaimed the deadly purpose
of that still approach. Upon the high poops, where floated the
standard of either nation, gathered round each chief the little knot of
officers through whom commands were issued and reports received,
the nerves along which thrilled the impulses of the great organism,
from its head, the admiral, through every member to the dark lowest
decks, nearly awash, where, as farthest from the captain’s own
oversight, the senior lieutenants controlled the action of the ships’
heaviest batteries.
On board the Queen Charlotte, Lord Howe, whose burden of sixty-
eight years had for four days found no rest save what he could snatch
in an arm-chair, now, at the prospect of battle, “displayed an
animation,” writes an eye-witness, “of which, at his age, and after
such fatigue of body and mind, I had not thought him capable. He
seemed to contemplate the result as one of unbounded satisfaction.”
By his side stood his fleet-captain, Curtis, of whose service among
the floating batteries, and during the siege of Gibraltar, the governor
of the fortress had said, “He is the man to whom the king is chiefly
indebted for its security;” and Codrington, then a lieutenant, who
afterwards commanded the allied fleets at Navarino. Five ships to the
left, Collingwood, in the Barfleur, was making to the admiral whose
flag she bore the remark that stirred Thackeray: “Our wives are now
about going to church, but we will ring about these Frenchmen’s ears
a peal which will drown their bells.” The French officers, both
admirals and captains, were mainly unknown men, alike then and
thereafter. The fierce flames of the Revolution had swept away the
men of the old school, mostly aristocrats, and time had not yet
brought forward the very few who during the Napoleonic period
showed marked capacity. The commander-in-chief, Villaret-Joyeuse,
had three years before been a lieutenant. He had a high record for
gallantry, but was without antecedents as a general officer. With him,
on the poop of the Montagne, which took her name from
Robespierre’s political supporters, stood that anomalous companion
of the generals and admirals of the day, the Revolutionary
commissioner, Jean Bon Saint-André, about to learn by experience
the practical working of the system he had advocated, to disregard all
tests of ability save patriotism and courage, depreciating practice and
skill as unnecessary to the valor of the true Frenchman.
As the British line drew near the French, Howe said to Curtis,
“Prepare the signal for close action.” “There is no such signal,”
replied Curtis. “No,” said the admiral, “but there is one for closer
action, and I only want that to be made in case of captains not doing
their duty.” Then closing a little signal book he always carried, he
continued to those around him, “Now, gentlemen, no more book, no
more signals. I look to you to do the duty of the Queen Charlotte in
engaging the flagship. I don’t want the ships to be bilge to bilge, but
if you can lock the yardarms, so much the better; the battle will be
the quicker decided.” His purpose was to go through the French line,
and fight the Montagne on the far side. Some doubted their
succeeding, but Howe overbore them. “That’s right, my lord!” cried
Bowen, the sailing-master, who looked to the ship’s steering. “The
Charlotte will make room for herself.” She pushed close under the
French ship’s stern, grazing her ensign, and raking her from stern to
stem with a withering fire, beneath which fell three hundred men. A
length or two beyond lay the French Jacobin. Howe ordered the
Charlotte to luff, and place herself between the two. “If we do,” said
Bowen, “we shall be on board one of them.” “What is that to you,
sir?” asked Howe quickly. “Oh!” muttered the master, not inaudibly.
“D—n my eyes if I care, if you don’t. I’ll go near enough to singe some
of our whiskers.” And then, seeing by the Jacobin’s rudder that she
was going off, he brought the Charlotte sharp round, her jib boom
grazing the second Frenchman as her side had grazed the flag of the
first.
From this moment the battle raged furiously from end to end of
the field for nearly an hour,—a wild scene of smoke and confusion,
under cover of which many a fierce ship duel was fought, while here
and there men wandered, lost, in a maze of bewilderment that
neutralized their better judgment. An English naval captain tells a
service tradition of one who was so busy watching the compass, to
keep his position in the ranks, that he lost sight of his antagonist, and
never again found him. Many a quaint incident passed, recorded or
unrecorded, under that sulphurous canopy. A British ship, wholly
dismasted, lay between two enemies, her captain desperately
wounded. A murmur of surrender was somewhere heard; but as the
first lieutenant checked it with firm authority, a cock flew upon the
stump of a mast and crowed lustily. The exultant note found quick
response in hearts not given to despair, and a burst of merriment,
accompanied with three cheers, replied to the bird’s triumphant
scream. On board the Brunswick, in her struggle with the Vengeur,
one of the longest and fiercest fights the sea has ever seen, the cocked
hat was shot off the effigy of the Duke of Brunswick, which she bore
as a figure-head. A deputation from the crew gravely requested the
captain to allow the use of his spare chapeau, which was securely
nailed on, and protected his grace’s wig during the rest of the action.
After this battle with the ships of the new republic, the partisans of
monarchy noted with satisfaction that, among the many royal figures
that surmounted the stems of the British fleet, not one lost his
crown. Of a harum-scarum Irish captain are told two droll stories.
After being hotly engaged for some time with a French ship, the fire
of the latter slackened, and then ceased. He called to know if she had
surrendered. The reply was, “No.” “Then,” shouted he, “d—n you,
why don’t you fire?” Having disposed of his special antagonist
without losing his own spars, the same man kept along in search of
new adventures, until he came to a British ship totally dismasted and
otherwise badly damaged. She was commanded by a captain of
rigidly devout piety. “Well, Jemmy,” hailed the Irishman, “you are
pretty well mauled; but never mind, Jemmy, whom the Lord loveth
he chasteneth.”
The French have transmitted to us less of anecdote, nor is it easy
to connect the thought of humor with those grimly earnest
republicans and the days of the Terror. There is, indeed, something
unintentionally funny in the remark of the commander of one of the
captured ships to his captors. They had, it was true, dismasted half
the French fleet, and had taken over a fourth; yet he assured them it
could not be considered a victory, “but merely a butchery, in which
the British had shown neither science nor tactics.” The one story,
noble and enduring, that will ever be associated with the French on
the 1st of June is in full keeping with the temper of the times and the
enthusiasm of the nation. The seventy-four-gun ship Vengeur, after a
three hours’ fight, yardarm to yardarm, with the British Brunswick,
was left in a sinking state by her antagonist, who was herself in no
condition to help. In the confusion, the Vengeur’s peril was for some
time not observed; and when it was, the British ships that came to
her aid had time only to remove part of her survivors. In their report
of the event the latter said: “Scarcely had the boats pulled clear of the
sides, when the most frightful spectacle was offered to our gaze.
Those of our comrades who remained on board the Vengeur du
Peuple, with hands raised to heaven, implored, with lamentable
cries, the help for which they could no longer hope. Soon
disappeared the ship and the unhappy victims it contained. In the
midst of the horror with which this scene inspired us all, we could
not avoid a feeling of admiration mingled with our grief. As we drew
away, we heard some of our comrades still offering prayers for the
welfare of their country. The last cries of these unfortunates were,
‘Vive la République!’ They died uttering them.” Over a hundred
Frenchmen thus went down.
Seven French ships were captured, including the sunk Vengeur.
Five more were wholly dismasted, but escaped,—a good fortune
mainly to be attributed to Howe’s utter physical prostration, due to
his advanced years and the continuous strain of the past five days.
He now went to bed, completely worn out. “We all got round him,”
wrote an officer, Lieutenant Codrington, who was present; “indeed, I
saved him from a tumble, he was so weak that from a roll of the ship
he was nearly falling into the waist. ‘Why, you hold me up as if I were
a child,’ he said good-humoredly.” Had he been younger, there can
be little doubt that the fruits of victory would have been gathered
with an ardor which his assistant, Curtis, failed to show.
23. Nelson’s Strategy at Copenhagen[67]

[In 1800 Russia, Sweden, and Denmark, under the manipulation


of Napoleon, formed a “League of Armed Neutrality” to resist British
restrictions on their trade with France. To reinforce diplomatic
pressure, Great Britain sent against the league a fleet of twenty ships,
of which Nelson was second in command under Sir Hyde Parker.
Throughout the campaign, writes Mahan, Nelson “lifted and carried
on his shoulders the dead weight of his superior.”—Editor.]
The fleet sailed from Yarmouth on the 12th of March, 1801; and on
the 19th, although there had been some scattering in a heavy gale,
nearly all were collected off the Skaw, the northern point of Jutland
at the entrance of the Kattegat. The wind being north-west was fair
for going to Copenhagen, and Nelson, if in command, would have
advanced at once with the ambassador on board. “While the
negotiation is going on,” he said, “the Dane should see our flag
waving every moment he lifted his head.” As it was, the envoy went
forward with a frigate alone and the fleet waited. On the 12th it was
off Elsineur, where the envoy rejoined, Denmark having rejected the
British terms.
This amounted to an acceptance of hostilities, and it only
remained to the commander-in-chief to act at once; for the wind was
favorable, an advantage which at any moment might be lost. On this
day Nelson addressed Parker a letter, summing up in a luminous
manner the features of the situation and the different methods of
action. “Not a moment should be lost in attacking,” he said; “we shall
never be so good a match for them as at this moment.” He next
hinted, what he had probably already said, that the fleet ought to
have been off Copenhagen, and not at Elsineur, when the negotiation
failed. “Then you might instantly attack and there would be scarcely
a doubt but the Danish fleet would be destroyed, and the capital
made so hot that Denmark would listen to reason and its true
interest.” Since, however, the mistake of losing so much time had
been made, he seeks to stir his superior to lose no more. “Almost the
safety, certainly the honor, of England is more entrusted to you than
ever yet fell to the lot of any British officer; ... never did our country
depend so much on the success of any fleet as of this.”
Having thus shown the necessity for celerity, Nelson next
discussed the plan of operations. Copenhagen is on the east side of
the island of Zealand, fronting the coast of Sweden, from which it is
separated by the passage called the Sound. On the west the island is
divided from the other parts of Denmark by the Great Belt. The
navigation of the latter being much the more difficult, the
preparations of the Danes had been made on the side of the Sound,
and chiefly about Copenhagen itself. For half a mile from the shore in
front of the city, flats extend, and in the Sound itself, at a distance of
little over a mile, is a long shoal called the Middle Ground. Between
these two bodies of shallow water is a channel, called the King’s,
through which a fleet of heavy ships could sail, and from whose
northern end a deep pocket stretches toward Copenhagen, forming
the harbor proper. The natural point of attack therefore appears to
be at the north; and there the Danes had erected powerful works,
rising on piles out of the shoal water off the harbor’s mouth and
known as the Three-Crown Batteries. Nelson, however, pointed out
that not only was this head of the line exceedingly strong, but that
the wind that was fair to attack would be foul to return; therefore a
disabled ship would have no escape but by passing through the
King’s Channel. Doing so she would have to run the gantlet of a line
of armed hulks, which the Danes had established as floating batteries
along the inner edge of the channel—covering the front of
Copenhagen—and would also be separated from her fleet. Nor was
this difficulty, which may be called tactical, the only objection to a
plan that he disparaged as “taking the bull by the horns.” He
remarked that so long as the British fleet remained in the Sound,
without entering the Baltic, the way was left open for both the
Swedes and the Russians, if released by the ice, to make a junction
with the Danes. Consequently, he advised that a sufficiently strong
force of the lighter ships-of-theline should pass outside the Middle
Ground, despite the difficulties of navigation, which were not
insuperable, and come up in rear of the city. There they would
interpose between the Danes and their allies, and be in position to
assail the weaker part of the hostile order. He offered himself to lead
this detachment.
This whole letter of March 24, 1801,[68] possesses peculiar interest;
for it shows with a rare particularity, elicited by the need he felt of
arousing and convincing his superior, Nelson’s clear discernment of
the decisive features of a military situation. The fame of this great
admiral has depended less upon his conduct of campaigns than upon
the renowned victories he won in the actual collision of fleet with
fleet; and even then has been mutilated by the obstinacy with which,
despite the perfectly evident facts, men have persisted in seeing in
them nothing but dash,—heart, not head. Throughout his
correspondence, it is true, there are frequent traces of the activity of
his mental faculties and of the general accuracy of his military
conclusions; but ordinarily it is from his actions that his reasonings
and principles must be deduced. In the present case we have the
views he held and the course he evidently would have pursued clearly
formulated by himself; and it cannot but be a subject of regret that
the naval world should have lost so fine an illustration as he would
there have given of the principles and conduct of naval warfare. He
concluded his letter with a suggestion worthy of Napoleon himself,
and which, if adopted, would have brought down the Baltic
Confederacy with a crash that would have resounded throughout
Europe. “Supposing us through the Belt with the wind first westerly,
would it not be possible to go with the fleet, or detach ten ships of
three and two decks, with one bomb and two fireships, to Revel, to
destroy the Russian squadron at that place? I do not see the great
risk of such a detachment, and with the remainder to attempt the
business at Copenhagen. The measure may be thought bold, but I am
of opinion the boldest are the safest; and our country demands a
most vigorous exertion of her force, directed with judgment.”
Committed as the Danes were to a stationary defense, this
recommendation to strike at the soul of the confederacy evinced the
clearest perception of the key to the situation, which Nelson himself
summed up in the following words: “I look upon the Northern
League to be like a tree, of which Paul was the trunk and Sweden and
Denmark the branches. If I can get at the trunk and hew it down, the
branches fall of course; but I may lop the branches and yet not be
able to fell the tree, and my power must be weaker when its greatest
strength is required”[69]—that is, the Russians should have been
attacked before the fleet was weakened, as it inevitably must be, by
the battle with the Danes. “If we could have cut up the Russian fleet,”
he said again, “that was my object.” Whatever Denmark’s wishes
about fighting, she was by her continental possessions tied to the
policy of Russia and Prussia, either of whom could overwhelm her by
land. She dared not disregard them. The course of both depended
upon the czar; for the temporizing policy of Prussia would at once
embrace his withdrawal from the league as an excuse for doing the
same. At Revel were twelve Russian ships-of-the-line, fully half their
Baltic fleet, whose destruction would have paralyzed the remainder
and the naval power of the empire. To persuade Parker to such a step
was, however, hopeless. “Our fleet would never have acted against
Russia and Sweden,” wrote Nelson afterwards, “although
Copenhagen would have been burned; for Sir Hyde Parker was
determined not to leave Denmark hostile in his rear;”[70] a reason
whose technical accuracy under all the circumstances was nothing
short of pedantic, and illustrates the immense distance between a
good and accomplished officer, which Parker was, and a genius
whose comprehension of rules serves only to guide, not to fetter, his
judgment.
Although unable to rise equal to the great opportunity indicated by
Nelson, Sir Hyde Parker adopted his suggestion as to the method and
direction of the principal attack upon the defenses of Copenhagen.
For this, Nelson asked ten ships-of-the-line and a number of smaller
vessels, with which he undertook to destroy the floating batteries
covering the front of the city. These being reduced, the bomb vessels
could be placed so as to play with effect upon the dockyard, arsenals,
and the town, in case further resistance was made.
[The fleet entered the Sound and anchored off Copenhagen on
March 26. On April 2 Nelson attacked from the southward as he had
suggested, and after a hard-fought battle forced a fourteen weeks’
armistice which practically secured the British aims, since it gave
opportunity to proceed against Sweden and Russia. Nelson was given
chief command on May 5, and two days later sailed for Revel, but the
death of the Czar Paul had already brought a favorable change in
Russia’s policy and made further action unnecessary.—Editor.]
24. England’s First Line of Defense[71]

[After the Copenhagen campaign, for a brief period in 1801,


Nelson commanded the naval defense forces in the Channel. When,
after two years of peace, hostilities were renewed in 1803, he sailed
in the Victory to take command in the Mediterranean. During the
following years of the war, “The British squadrons, hugging the
French coasts and blocking the French arsenals, were the first line of
defense, covering British interests from the Baltic to Egypt, the
British colonies in the four quarters of the globe, and the British
merchantmen which whitened every sea.”[72]—Editor.]
Meanwhile that period of waiting from May, 1803, to August,
1805, when the tangled net of naval and military movements began
to unravel, was a striking and wonderful pause in the world’s history.
On the heights above Boulogne, and along the narrow strip of beach
from Étaples to Vimereux, were encamped one hundred and thirty
thousand of the most brilliant soldiery of all time, the soldiers who
had fought in Germany, Italy, and Egypt, soldiers who were yet to
win, from Austria, Ulm and Austerlitz, and from Prussia, Auerstadt
and Jena, to hold their own, though barely, at Eylau against the army
of Russia, and to overthrow it also, a few months later, on the bloody
field of Friedland. Growing daily more vigorous in the bracing sea air
and the hardy life laid out for them, they could on fine days, as they
practised the varied maneuvers which were to perfect the vast host in
embarking and disembarking with order and rapidity, see the white
cliffs fringing the only country that to the last defied their arms. Far
away, Cornwallis off Brest, Collingwood off Rochefort, Pellew off
Ferrol, were battling the wild gales of the Bay of Biscay, in that
tremendous and sustained vigilance which reached its utmost
tension in the years preceding Trafalgar, concerning which
Collingwood wrote that admirals need to be made of iron, but which
was forced upon them by the unquestionable and imminent danger
of the country. Farther distant still, severed apparently from all
connection with the busy scene at Boulogne, Nelson before Toulon
was wearing away the last two years of his glorious but suffering life,
fighting the fierce north-westers of the Gulf of Lyon and questioning,
questioning continually with feverish anxiety, whether Napoleon’s
object was Egypt again or Great Britain really. They were dull, weary,
eventless months, those months of watching and waiting of the big
ships before the French arsenals. Purposeless they surely seemed to
many, but they saved England. The world has never seen a more
impressive demonstration of the influence of sea power upon its
history. Those far distant, storm-beaten ships, upon which the Grand
Army never looked, stood between it and the dominion of the world.
Holding the interior positions they did, before—and therefore
between—the chief dockyards and detachments of the French navy,
the latter could unite only by a concurrence of successful evasions, of
which the failure of any one nullified the result. Linked together as
the various British fleets were by chains of smaller vessels, chance
alone could secure Bonaparte’s great combination, which depended
upon the covert concentration of several detachments upon a point
practically within the enemy’s lines. Thus, while bodily present
before Brest, Rochefort, and Toulon, strategically the British
squadrons lay in the Straits of Dover barring the way against the
Army of Invasion.
The Straits themselves, of course, were not without their own
special protection. Both they and their approaches, in the broadest
sense of the term, from the Texel to the Channel Islands, were
patrolled by numerous frigates and smaller vessels, from one
hundred to a hundred and fifty in all. These not only watched
diligently all that happened in the hostile harbors and sought to
impede the movements of the flat-boats, but also kept touch with
and maintained communication between the detachments of ships-
of-the-line. Of the latter, five off the Texel watched the Dutch navy,
while others were anchored off points of the English coast with
reference to probable movements of the enemy. Lord St. Vincent,
whose ideas on naval strategy were clear and sound, though he did
not use the technical terms of the art, discerned and provided against
the very purpose entertained by Bonaparte, of a concentration before
Boulogne by ships drawn from the Atlantic and Mediterranean. The
best security, the most advantageous strategic positions, were
doubtless those before the enemy’s ports; and never in the history of
blockades has there been excelled, if ever equalled, the close locking
of Brest by Admiral Cornwallis, both winter and summer, between
the outbreak of war and the battle of Trafalgar. It excited not only the
admiration but the wonder of contemporaries.[73] In case, however,
the French at Brest got out, so the prime minister of the day
informed the speaker of the House, Cornwallis’s rendezvous was off
the Lizard (due north of Brest), so as to go for Ireland, or follow the
French up Channel, if they took either direction. Should the French
run for the Downs, the five sail of the line at Spithead would also
follow them; and Lord Keith (in the Downs) would in addition to his
six, and six block ships, have also the North Sea fleet at his
command.[74] Thus provision was made, in case of danger, for the
outlying detachments to fall back on the strategic center, gradually
accumulating strength, till they formed a body of from twenty-five to
thirty heavy and disciplined ships-of-the-line, sufficient to meet all
probable contingencies.
Hence, neither the Admiralty nor British naval officers in general
shared the fears of the country concerning the peril from the flotilla.
“Our first defense,” wrote Nelson in 1801, “is close to the enemy’s
ports; and the Admiralty have taken such precautions, by having
such a respectable force under my orders, that I venture to express a
well-grounded hope that the enemy would be annihilated before they
get ten miles from their own shores.”[75]
25. The Battle of Trafalgar[76]

[While Napoleon’s plans for control of the Channel underwent


many changes, the movements actually carried out were as follows:
On March 27, Villeneuve with eighteen ships left Toulon and sailed
for the West Indies, arriving at Martinique May 12, where he was to
be joined by the Brest fleet. Baffled at first by head winds and
uncertainty as to the enemy’s destination, Nelson reached Barbados
twenty-three days later.
Learning of his arrival, Villeneuve at once sailed for Europe, on
June 9, again followed, four days later by Nelson. The brig Curieux,
despatched by Nelson to England on the 12th, sighted the enemy
fleet and reported its approach to the Admiralty, thus enabling
Calder to meet Villeneuve in an indecisive action on July 22 off
Ferrol, Spain. Nelson steered for Gibraltar, and thence, having
learned that Villeneuve was to the northward, for the Channel, where
on August 15 he left his ships with the Channel fleet under
Cornwallis.

The French now had twenty-one ships at Brest and twenty-nine


under Villeneuve at Ferrol, while Cornwallis stood between with
thirty-four or thirty-five. An effective French combination was still
possible, especially as Cornwallis made the cardinal error of dividing
his fleet. Accordingly, Villeneuve, under an imperative summons
from Napoleon, left Ferrol on August 13; but, with his ships
demoralized by their long cruise, with head winds, and disturbed by
false reports from a Danish merchantman regarding the British
strength, the French admiral two days later turned for Cadiz. Here he
was watched by Collingwood; and on September 28 Nelson, after
three weeks in England, took command of the blockading fleet.
“Thus ended, and forever,” writes Mahan, “Napoleon’s profoundly
conceived and laboriously planned scheme for the invasion of
England. If it be sought to fix a definite moment which marked the
final failure of so vast a plan, that one may well be chosen when
Villeneuve made signal to bear up for Cadiz.”[77] On August 25 the
Boulogne army broke camp and marched against the Austrian forces
advancing toward the Rhine.—Editor.]
The importance attached by the emperor to his project was not
exaggerated. He might, or he might not, succeed; but, if he failed
against Great Britain, he failed everywhere. This he, with the
intuition of genius, felt; and to this the record of his after history now
bears witness. To the strife of arms with the great Sea Power
succeeded the strife of endurance. Amid all the pomp and
circumstance of the war which for ten years to come desolated the
Continent, amid all the tramping to and fro over Europe of the
French armies and their auxiliary legions, there went on unceasingly
that noiseless pressure upon the vitals of France, that compulsion,
whose silence, when once noted, becomes to the observer the most
striking and awful mark of the working of Sea Power. Under it the
resources of the Continent wasted more and more with each
succeeding year; and Napoleon, amid all the splendor of his imperial
position, was ever needy. To this, and to the immense expenditures
required to enforce the Continental System, are to be attributed most
of those arbitrary acts which made him the hated of the peoples, for
whose enfranchisement he did so much. Lack of revenue and lack of
credit, such was the price paid by Napoleon for the Continental
System, through which alone, after Trafalgar, he hoped to crush the
Power of the Sea. It may be doubted whether, amid all his glory, he
ever felt secure after the failure of the invasion of England. To
borrow his own vigorous words, in the address to the nation issued
before he joined the army, “To live without commerce, without
shipping, without colonies, subjected to the unjust will of our
enemies, is to live as Frenchmen should not.” Yet so had France to
live throughout his reign, by the will of the one enemy never
conquered.
On the 14th of September, before quitting Paris, Napoleon sent
Villeneuve orders to take the first favorable opportunity to leave
Cadiz, to enter the Mediterranean, join the ships at Cartagena, and
with this combined force move upon southern Italy. There, at any
suitable point, he was to land the troops embarked in the fleet to
reinforce General St. Cyr, who already had instructions to be ready to
attack Naples at a moment’s notice.[78] The next day these orders
were reiterated to Decrès, enforcing the importance to the general
campaign of so powerful a diversion as the presence of this great fleet
in the Mediterranean; but, as “Villeneuve’s excessive pusillanimity
will prevent him from undertaking this, you will send to replace him
Admiral Rosily, who will bear letters directing Villeneuve to return to
France and give an account of his conduct.”[79] The emperor had
already formulated his complaints against the admiral under seven
distinct heads.[80] On the 15th of September, the same day the orders
to relieve Villeneuve were issued, Nelson, having spent at home only
twenty-five days, left England for the last time. On the 28th, when he
joined the fleet off Cadiz, he found under his command twenty-nine
ships-of-the-line, which successive arrivals raised to thirty-three by
the day of the battle; but, water running short, it became necessary to
send the ships, by divisions of six, to fill up at Gibraltar. To this cause
was due that only twenty-seven British vessels were present in the
action,—an unfortunate circumstance; for, as Nelson said, what the
country wanted was not merely a splendid victory, but annihilation;
“numbers only can annihilate.”[81] The force under his command was
thus disposed: the main body about fifty miles west-south-west of
Cadiz, seven lookout frigates close in with the port, and between
these extremes, two small detachments of ships-of-the-line,—the one
twenty miles from the harbor, the other about thirty-five. “By this
chain,” he wrote, “I hope to have constant communication with the
frigates.”

“The Nelson Touch”[82]


At 6 P.M. of Saturday, September 28, the Victory reached the fleet,
then numbering twenty-nine of the line; the main body being fifteen
to twenty miles west of Cadiz, with six ships close in with the port.
The next day was Nelson’s birthday—forty-seven years old. The
junior admirals and the captains visited the commander-in-chief, as
customary, but with demonstrations of gladness and confidence that
few leaders have elicited in equal measure from their followers. “The
reception I met with on joining the fleet caused the sweetest
sensation of my life. The officers who came on board to welcome my
return, forgot my rank as commander-in-chief in the enthusiasm
with which they greeted me. As soon as these emotions were past, I
laid before them the plan I had previously arranged for attacking the
enemy; and it was not only my pleasure to find it generally approved,
but clearly perceived and understood.” To Lady Hamilton he gave an
account of this scene which differs little from the above, except in its
greater vividness. “I believe my arrival was most welcome, not only
to the commander of the fleet, but also to every individual in it; and,
when I came to explain to them the ‘Nelson touch,’ it was like an
electric shock. Some shed tears, all approved—‘It was new—it was
singular—it was simple!’ and, from admirals downwards, it was
repeated—‘It must succeed, if ever they will allow us to get at them!
You are, my Lord, surrounded by friends whom you inspire with
confidence.’ Some may be Judas’s; but the majority are certainly
much pleased with my commanding them.” No more joyful birthday
levee was ever held than that of this little naval court. Besides the
adoration for Nelson personally, which they shared with their
countrymen in general, there mingled with the delight of the captains
the sentiment of professional appreciation and confidence, and a
certain relief, noticed by Codrington, from the dry, unsympathetic
rule of Collingwood, a man just, conscientious, highly trained, and
efficient, but self-centered, rigid, uncommunicative; one who
fostered, if he did not impose, restrictions upon the intercourse
between the ships, against which he had inveighed bitterly when
himself one of St. Vincent’s captains. Nelson, on the contrary, at once
invited cordial social relations with the commanding officers. Half of
the thirty-odd were summoned to dine on board the flagship the first
day, and half the second. Not till the third did he permit himself the
luxury of a quiet dinner chat with his old chum, the second in
command, whose sterling merits, under a crusty exterior, he knew
and appreciated. Codrington mentions also an incident, trivial in
itself, but illustrative of that outward graciousness of manner, which,
in a man of Nelson’s temperament and position, is rarely the result of
careful cultivation, but bespeaks rather the inner graciousness of the
heart that he abundantly possessed. They had never met before, and
the admiral, greeting him with his usual easy courtesy, handed him a
letter from his wife, saying that being entrusted with it by a lady, he
made a point of delivering it himself, instead of sending it by
another.
The “Nelson Touch,” or Plan of Attack, expounded to his captains
at the first meeting, was afterwards formulated in an Order, copies of
which were issued to the fleet on the 9th of October. In this
“Memorandum,” which was doubtless sufficient for those who had
listened to the vivid oral explanation of its framer, the writer finds
the simplicity, but not the absolute clearness, that they recognized. It
embodies, however, the essential ideas, though not the precise
method of execution, actually followed at Trafalgar, under conditions
considerably different from those which Nelson probably
anticipated; and it is not the least of its merits as a military
conception that it could thus, with few signals and without
confusion, adapt itself at a moment’s notice to diverse circumstances.
This great order not only reflects the ripened experience of its
author, but contains also the proof of constant mental activity and
development in his thought; for it differs materially in detail from
the one issued a few months before to the fleet, when in pursuit of
Villeneuve to the West Indies.

MEMORANDUM

(Secret)
Victory, off Cadiz, 9th October, 1805.

Thinking it almost impossible to bring a Fleet of forty Sail of the


Line into a Line of Battle in variable winds, thick weather, and other
circumstances which must occur, without such a loss of time that the
opportunity would probably be lost of bringing the Enemy to Battle
in such a manner as to make the business decisive, I have therefore
made up my mind to keep the Fleet in that position of sailing (with
the exception of the First and Second in Command) that the Order of
Sailing is to be the Order of Battle, placing the Fleet in two Lines of
sixteen Ships each, with an Advanced Squadron of eight of the fastest
sailing Two-decked Ships, which will always make, if wanted, a Line
of twenty-four Sail, on whichever Line the Commander-in-Chief may
direct.
The Second in Command will, after my intentions are made known
to him, have the entire direction of his Line to make the attack upon
the Enemy, and to follow up the blow until they are captured or
destroyed.
If the Enemy’s Fleet should be seen to windward in Line of Battle,
and that the two Lines and the Advanced Squadron can fetch them,
they will probably be so extended that their Van could not succor
their Rear.
I should therefore probably make the Second in Command’s signal
to lead through, about their twelfth Ship from their Rear, (or
wherever he could fetch, if not able to get so far advanced); my Line
would lead through about their Center, and the Advanced Squadron
to cut two or three or four Ships ahead of their Center, so as to
ensure getting at their Commander-in-Chief, on whom every effort
must be made to capture.
The whole impression of the British Fleet must be to overpower
from two or three Ships ahead of their Commander-in-Chief,
supposed to be in the Center, to the Rear of their Fleet. I will suppose
twenty Sail of the Enemy’s Line to be untouched, it must be some
time before they could perform a maneuver to bring their force
compact to attack any part of the British Fleet engaged, or to succor
their own Ships, which indeed would be impossible without mixing
with the Ships engaged.
Something must be left to chance; nothing is sure in a Sea Fight
beyond all others. Shot will carry away the masts and yards of friends
as well as foes; but I look with confidence to a Victory before the Van
of the Enemy could succor their Rear, and then that the British Fleet
would most of them be ready to receive their twenty Sail of the Line,
or to pursue them, should they endeavor to make off.
If the Van of the Enemy tacks, the Captured Ships must run to
leeward of the British Fleet; if the Enemy wears, the British must

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